Provider Demographics
NPI:1811595929
Name:IDAHO STATE UNIVERSITY
Entity Type:Organization
Organization Name:IDAHO STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICS DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-373-1743
Mailing Address - Street 1:921 S 8TH AVE STOP 8120
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0002
Mailing Address - Country:US
Mailing Address - Phone:208-240-1609
Mailing Address - Fax:
Practice Address - Street 1:1400 E TERRY DR BLDG 63
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-240-1690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty