Provider Demographics
NPI:1740463132
Name:IDAHO CENTER FOR AUTISM, LLC
Entity type:Organization
Organization Name:IDAHO CENTER FOR AUTISM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MED
Authorized Official - Phone:208-342-0374
Mailing Address - Street 1:PO BOX 706
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83680-0706
Mailing Address - Country:US
Mailing Address - Phone:208-342-0374
Mailing Address - Fax:
Practice Address - Street 1:5353 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1112
Practice Address - Country:US
Practice Address - Phone:208-342-0374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8078750251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management