Provider Demographics
NPI:1891913125
Name:ABUNDANCE BEHAVIORAL HEALTH SERVICE INC.
Entity Type:Organization
Organization Name:ABUNDANCE BEHAVIORAL HEALTH SERVICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:LSW I
Authorized Official - Phone:208-455-1222
Mailing Address - Street 1:524 CLEVELAND BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4080
Mailing Address - Country:US
Mailing Address - Phone:208-455-1222
Mailing Address - Fax:208-455-2559
Practice Address - Street 1:524 CLEVELAND BLVD STE 230
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4080
Practice Address - Country:US
Practice Address - Phone:208-455-1222
Practice Address - Fax:208-455-2559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDZC217184C104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty