Provider Demographics
NPI:1396326096
Name:AUTUMN LEAVES PSYCHIATRY, PLLC
Entity type:Organization
Organization Name:AUTUMN LEAVES PSYCHIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MERJURIE
Authorized Official - Middle Name:F
Authorized Official - Last Name:RICKLEFS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP, PMHNP-BC
Authorized Official - Phone:208-821-0357
Mailing Address - Street 1:3670 S 25TH E STE 4
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4956
Mailing Address - Country:US
Mailing Address - Phone:208-821-0357
Mailing Address - Fax:
Practice Address - Street 1:3670 S 25TH E STE 4
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4956
Practice Address - Country:US
Practice Address - Phone:208-821-0357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-15
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty