Provider Demographics
NPI:1396447231
Name:WOLVERINE CANYON COUNSELING, LLC
Entity type:Organization
Organization Name:WOLVERINE CANYON COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DALLEN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-520-1502
Mailing Address - Street 1:1434 N 615 E
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-5077
Mailing Address - Country:US
Mailing Address - Phone:208-520-1502
Mailing Address - Fax:
Practice Address - Street 1:1434 N 615 E
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-5077
Practice Address - Country:US
Practice Address - Phone:208-520-1502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty