Provider Demographics
NPI:1851423446
Name:PANHANDLE BEHAVIOAL HEALTH
Entity Type:Organization
Organization Name:PANHANDLE BEHAVIOAL HEALTH
Other - Org Name:PANHANDLE HORIZONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ELMO
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:406-745-0148
Mailing Address - Street 1:32126 ALLISON RD
Mailing Address - Street 2:
Mailing Address - City:ST IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865-9155
Mailing Address - Country:US
Mailing Address - Phone:406-745-0148
Mailing Address - Fax:208-667-2681
Practice Address - Street 1:212 S 11TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4000
Practice Address - Country:US
Practice Address - Phone:208-755-6121
Practice Address - Fax:208-667-2681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-10
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806144500Medicaid
IDPSY90OtherPSYCHOLOGY LICENSE
IDR34117Medicare UPIN
ID001633300Medicare ID - Type Unspecified