Provider Demographics
NPI:1215622048
Name:MENTAL HEALTH CLINIC OF IDAHO PLLC
Entity type:Organization
Organization Name:MENTAL HEALTH CLINIC OF IDAHO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:PHUYAL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:979-332-4184
Mailing Address - Street 1:6737 E DEER RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-7147
Mailing Address - Country:US
Mailing Address - Phone:979-332-4184
Mailing Address - Fax:
Practice Address - Street 1:6737 E DEER RIDGE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-7147
Practice Address - Country:US
Practice Address - Phone:979-332-4184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-07
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1760157598OtherNPI