Provider Demographics
NPI:1790997955
Name:INDEPENDENT GROWTH
Entity Type:Organization
Organization Name:INDEPENDENT GROWTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-678-9165
Mailing Address - Street 1:PO BOX 756
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-0756
Mailing Address - Country:US
Mailing Address - Phone:208-678-9165
Mailing Address - Fax:208-679-5985
Practice Address - Street 1:2173 OVERLAND AVE
Practice Address - Street 2:BOX 756
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2927
Practice Address - Country:US
Practice Address - Phone:208-678-9165
Practice Address - Fax:208-679-5985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0027664Medicaid
ID0027665Medicaid