Provider Demographics
NPI:1801274790
Name:INTEGRATED COUNSELING AND WELLNESS OF REXBURG
Entity type:Organization
Organization Name:INTEGRATED COUNSELING AND WELLNESS OF REXBURG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:EINERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LAMFT
Authorized Official - Phone:208-357-3104
Mailing Address - Street 1:101 E MAIN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2017
Mailing Address - Country:US
Mailing Address - Phone:208-357-3104
Mailing Address - Fax:888-990-2826
Practice Address - Street 1:101 E MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2017
Practice Address - Country:US
Practice Address - Phone:208-357-3104
Practice Address - Fax:888-990-2826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5636261QM0850X, 261QM0855X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health