Provider Demographics
NPI:1386476380
Name:RESTORATION WELLNESS OF IDAHO LLC
Entity type:Organization
Organization Name:RESTORATION WELLNESS OF IDAHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:ELISH
Authorized Official - Last Name:LONG-AZARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-794-4737
Mailing Address - Street 1:PO BOX 171362
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83717-1362
Mailing Address - Country:US
Mailing Address - Phone:208-794-4737
Mailing Address - Fax:
Practice Address - Street 1:3164 E EASTGATE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-5637
Practice Address - Country:US
Practice Address - Phone:208-794-4737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-17
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No171R00000XOther Service ProvidersInterpreterGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty