Provider Demographics
NPI:1134361207
Name:CLEARWATER COUNSELING
Entity type:Organization
Organization Name:CLEARWATER COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-743-8101
Mailing Address - Street 1:1020 MAIN ST
Mailing Address - Street 2:PO BOX 1123
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1842
Mailing Address - Country:US
Mailing Address - Phone:208-743-8101
Mailing Address - Fax:208-746-7402
Practice Address - Street 1:318 1/2 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-2238
Practice Address - Country:US
Practice Address - Phone:208-983-7717
Practice Address - Fax:208-983-7787
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEARWATER COUNSELING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW1120261QM0850X
IDLCPC4218261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807373700Medicaid