Provider Demographics
NPI:1649756057
Name:CITY CREEK COUNSELING, LLC
Entity Type:Organization
Organization Name:CITY CREEK COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANDICE
Authorized Official - Middle Name:CHAELEE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:208-339-0909
Mailing Address - Street 1:1219 YELLOWSTONE AVE STE D
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4368
Mailing Address - Country:US
Mailing Address - Phone:208-339-0909
Mailing Address - Fax:208-339-0909
Practice Address - Street 1:1219 YELLOWSTONE AVE STE D
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4368
Practice Address - Country:US
Practice Address - Phone:208-339-0909
Practice Address - Fax:208-339-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID=========OtherPRIVATE INSURANCE