Provider Demographics
NPI:1932856135
Name:MOUNTAIN HOME BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:MOUNTAIN HOME BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REYSAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:COTTON
Authorized Official - Suffix:
Authorized Official - Credentials:BS RN
Authorized Official - Phone:208-409-7122
Mailing Address - Street 1:1225 E 18TH N
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-1822
Mailing Address - Country:US
Mailing Address - Phone:208-409-7122
Mailing Address - Fax:
Practice Address - Street 1:1815 AMERICAN LEGION BLVD STE A
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3166
Practice Address - Country:US
Practice Address - Phone:208-409-7122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-07
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty