Provider Demographics
NPI:1356564405
Name:NORTHWEST PROFESSIONALS FAMILY RESOURCE CENTER
Entity type:Organization
Organization Name:NORTHWEST PROFESSIONALS FAMILY RESOURCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:208-376-0979
Mailing Address - Street 1:PO BOX 44689
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-0689
Mailing Address - Country:US
Mailing Address - Phone:208-376-0979
Mailing Address - Fax:208-378-1089
Practice Address - Street 1:6540 W EMERALD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8782
Practice Address - Country:US
Practice Address - Phone:208-376-0979
Practice Address - Fax:208-378-1089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8L105OtherBLUE CROSS OF IDAHO