Provider Demographics
NPI:1891825824
Name:IDAHO DEPT OF HEALTH & WELFARE REGION 4 CMH PSR BOISE
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE REGION 4 CMH PSR BOISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:208-334-0969
Mailing Address - Street 1:1720 WESTGATE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7164
Mailing Address - Country:US
Mailing Address - Phone:208-334-0792
Mailing Address - Fax:208-334-0812
Practice Address - Street 1:1720 WESTGATE DR
Practice Address - Street 2:SUITE D
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7164
Practice Address - Country:US
Practice Address - Phone:208-334-0792
Practice Address - Fax:208-334-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010019129OtherBLUE SHIELD
HW090OtherBLUE CROSS OF IDAHO
ID0028402Medicaid