Provider Demographics
NPI:1710287149
Name:IDAHO DIVISION OF BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:IDAHO DIVISION OF BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SKIPPEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-334-6676
Mailing Address - Street 1:450 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6056
Mailing Address - Country:US
Mailing Address - Phone:208-334-6997
Mailing Address - Fax:
Practice Address - Street 1:450 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6056
Practice Address - Country:US
Practice Address - Phone:208-334-6997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8082697Medicaid