Provider Demographics
NPI:1063918464
Name:IDAHO PSYCHOLOGICAL RESOURCES LLC
Entity type:Organization
Organization Name:IDAHO PSYCHOLOGICAL RESOURCES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-604-5193
Mailing Address - Street 1:PO BOX 402
Mailing Address - Street 2:
Mailing Address - City:MACKAY
Mailing Address - State:ID
Mailing Address - Zip Code:83251-0402
Mailing Address - Country:US
Mailing Address - Phone:208-588-2770
Mailing Address - Fax:208-588-2984
Practice Address - Street 1:4433 BEVERLAND ROAD
Practice Address - Street 2:
Practice Address - City:MACKAY
Practice Address - State:ID
Practice Address - Zip Code:83251
Practice Address - Country:US
Practice Address - Phone:208-588-5770
Practice Address - Fax:208-588-2984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-04
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3661101YA0400X
IDLCSW-27821104100000X
IDLCSW-24942104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID=========Medicaid