Provider Demographics
NPI:1841470887
Name:CENTRAL MOUNTAINS COUNSELING, PLLC
Entity type:Organization
Organization Name:CENTRAL MOUNTAINS COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-630-4040
Mailing Address - Street 1:PO BOX 2553
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-2553
Mailing Address - Country:US
Mailing Address - Phone:208-630-4040
Mailing Address - Fax:208-634-4055
Practice Address - Street 1:301 DEINHARD LN
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-4703
Practice Address - Country:US
Practice Address - Phone:208-630-4040
Practice Address - Fax:208-634-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-30132251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8PO33OtherBLUE CROSS
ID40230OtherREGENCE BLUE SHIELD
ID40230OtherREGENCE BLUE SHIELD