Provider Demographics
NPI:1811451438
Name:IDAHO INSTITUTE OF GENDER AND SEX THERAPY
Entity type:Organization
Organization Name:IDAHO INSTITUTE OF GENDER AND SEX THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:IRVIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, MED, CST
Authorized Official - Phone:208-417-8428
Mailing Address - Street 1:3278 E RENWICK ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6467
Mailing Address - Country:US
Mailing Address - Phone:208-417-8428
Mailing Address - Fax:208-216-1434
Practice Address - Street 1:6003 W OVERLAND RD STE 105
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-3075
Practice Address - Country:US
Practice Address - Phone:208-417-8428
Practice Address - Fax:208-216-1434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-28
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty