Provider Demographics
NPI:1750157400
Name:LOST RIVER COUNSELING PLLC
Entity type:Organization
Organization Name:LOST RIVER COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-219-6304
Mailing Address - Street 1:113 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5909
Mailing Address - Country:US
Mailing Address - Phone:208-219-6304
Mailing Address - Fax:
Practice Address - Street 1:1070 RIVERWALK DR STE 264
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3343
Practice Address - Country:US
Practice Address - Phone:208-219-7655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)