Provider Demographics
NPI:1275675886
Name:SAND CREEK MENTAL HEALTH AND WELLNESS
Entity type:Organization
Organization Name:SAND CREEK MENTAL HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:208-263-7180
Mailing Address - Street 1:212 N 1ST AVE STE G101
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1400
Mailing Address - Country:US
Mailing Address - Phone:208-263-7180
Mailing Address - Fax:208-255-2017
Practice Address - Street 1:212 N 1ST AVE STE G101
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1400
Practice Address - Country:US
Practice Address - Phone:208-263-7180
Practice Address - Fax:208-255-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-2054104100000X
IDLCSW-260841041C0700X
IDLCSW-3351041C0700X
IDLMFT-2843106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1368886Medicare ID - Type UnspecifiedGROUP NUMBER