Provider Demographics
NPI:1285959908
Name:IDAHO PSYCHIATRIC INSTITUTE
Entity type:Organization
Organization Name:IDAHO PSYCHIATRIC INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:THURBER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:208-529-4300
Mailing Address - Street 1:1975 MARTHA AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7580
Mailing Address - Country:US
Mailing Address - Phone:208-529-4300
Mailing Address - Fax:208-529-1627
Practice Address - Street 1:1975 MARTHA AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7580
Practice Address - Country:US
Practice Address - Phone:208-529-4300
Practice Address - Fax:208-529-1627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT965225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808091400Medicaid
ID808091300Medicaid