Provider Demographics
NPI:1629825526
Name:EAST IDAHO MENTAL HEALTH LLC
Entity type:Organization
Organization Name:EAST IDAHO MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DESTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:THAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-359-2101
Mailing Address - Street 1:859 S YELLOWSTONE HWY STE 3201
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-6200
Mailing Address - Country:US
Mailing Address - Phone:208-359-2101
Mailing Address - Fax:
Practice Address - Street 1:859 S YELLOWSTONE HWY STE 3201
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-6200
Practice Address - Country:US
Practice Address - Phone:208-359-2101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-30
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty