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Organization
IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH PSR BONNERS FERRY
Active
Organization
IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH PSR BONNERS FERRY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CORA JO GUSSENHOVEN (PROGRAM MANAGER)
(208) 769-1406
Entity
Organization
Contact information
Practice address
RT 4 6522 TAMARACK LN, BONNERS FERRY, ID 83805-9805
(208) 267-3187
(208) 267-3251
Mailing address
RT 4 6522 TAMARACK LN, BONNERS FERRY, ID 83805-9805
(208) 267-3187
(208) 267-3251
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010018348
BLUE SHIELD
—
05
—
8073521
—
ID
01
—
HW256
BLUE CROSS OF IDAHO
—
Enumeration date
02/28/2007
Last updated
08/22/2020
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