Provider Demographics
NPI:1821344367
Name:STATE AVENUE OFFICES
Entity Type:Organization
Organization Name:STATE AVENUE OFFICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAMILLA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CAFFERTY
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:208-994-3599
Mailing Address - Street 1:39 E STATE AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2342
Mailing Address - Country:US
Mailing Address - Phone:208-994-3599
Mailing Address - Fax:208-473-2206
Practice Address - Street 1:39 E STATE AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2342
Practice Address - Country:US
Practice Address - Phone:208-994-3599
Practice Address - Fax:208-473-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-02
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health