Provider Demographics
NPI:1962263897
Name:CRESWELL COUNSELING CENTER LLC
Entity type:Organization
Organization Name:CRESWELL COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:LADACY
Authorized Official - Last Name:LUQUE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:208-863-1404
Mailing Address - Street 1:4172 N CRESWELL WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2403
Mailing Address - Country:US
Mailing Address - Phone:208-863-1404
Mailing Address - Fax:833-340-7217
Practice Address - Street 1:4172 N CRESWELL WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2403
Practice Address - Country:US
Practice Address - Phone:208-863-1404
Practice Address - Fax:833-340-7217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-18
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID7365212Medicaid
ID200000014376OtherBLUE CROSS OF IDAHO