Provider Demographics
NPI:1790806065
Name:TREASURE VALLEY BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:TREASURE VALLEY BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER /THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRADI
Authorized Official - Middle Name:
Authorized Official - Last Name:FRITTS
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:208-452-7705
Mailing Address - Street 1:131 N WHITLEY DR.
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619
Mailing Address - Country:US
Mailing Address - Phone:208-452-7705
Mailing Address - Fax:208-452-7750
Practice Address - Street 1:131 N WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2172
Practice Address - Country:US
Practice Address - Phone:208-452-7705
Practice Address - Fax:208-452-7750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807398400Medicaid