Provider Demographics
NPI:1881353175
Name:INTEGRATED COUNSELING AND WELLNESS EATING DISORDER CENTER OF REXBURG
Entity type:Organization
Organization Name:INTEGRATED COUNSELING AND WELLNESS EATING DISORDER CENTER OF REXBURG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:EINERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-403-1826
Mailing Address - Street 1:101 E MAIN ST STE 211
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:
Practice Address - Street 1:101 E MAIN ST STE 211
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-14
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty