Provider Demographics
NPI:1770647612
Name:EMMETT FAMILY SERVICES
Entity Type:Organization
Organization Name:EMMETT FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LMHP
Authorized Official - Phone:208-559-7773
Mailing Address - Street 1:501 N 16TH ST
Mailing Address - Street 2:STE 108 & 110
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-2781
Mailing Address - Country:US
Mailing Address - Phone:208-642-2600
Mailing Address - Fax:208-642-6164
Practice Address - Street 1:501 N 16TH ST
Practice Address - Street 2:STE 108 & 110
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2781
Practice Address - Country:US
Practice Address - Phone:208-642-2600
Practice Address - Fax:208-642-6164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID26695104100000X
ID242101041C0700X
ID446A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806575100Medicaid
ID806586200Medicaid