Provider Demographics
NPI:1801000112
Name:ALTA ADDICTIONS AND MENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:ALTA ADDICTIONS AND MENTAL HEALTH SERVICES
Other - Org Name:ALTA SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONNEL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-395-1713
Mailing Address - Street 1:5223 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2637
Mailing Address - Country:US
Mailing Address - Phone:208-395-1713
Mailing Address - Fax:208-395-1715
Practice Address - Street 1:5223 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2637
Practice Address - Country:US
Practice Address - Phone:208-395-1713
Practice Address - Fax:208-395-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 1100251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8064161Medicaid