Provider Demographics
NPI:1124124797
Name:FAMILY SUPPORT SERVICES OF NORTH IDAHO
Entity type:Organization
Organization Name:FAMILY SUPPORT SERVICES OF NORTH IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:208-769-4222
Mailing Address - Street 1:1115 W IRONWOOD DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4936
Mailing Address - Country:US
Mailing Address - Phone:208-769-4222
Mailing Address - Fax:208-667-7557
Practice Address - Street 1:1115 W IRONWOOD DR
Practice Address - Street 2:SUITE C
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4936
Practice Address - Country:US
Practice Address - Phone:208-769-4222
Practice Address - Fax:208-667-7557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty