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Organization
IDAHO DEPT OF HEALTH & WELFARE REG 1 AHM PSR SANDPOINT
Active
Organization
IDAHO DEPT OF HEALTH & WELFARE REG 1 AHM PSR SANDPOINT
Active
Organization subpart
No
Provider details
NPI number
Authorized official
HOLLY BONWELL (PROGRAM MANAGER)
(208) 769-1406
Entity
Organization
Contact information
Practice address
207 LARKSPUR ST, PONDERAY, ID 83852-5011
(208) 265-4535
(208) 263-4198
Mailing address
207 LARKSPUR ST, PONDERAY, ID 83852-5011
(208) 265-4535
(208) 263-4198
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
—
8073518
—
ID
01
—
HW256
BLUE CROSS OF IDAHO
—
Enumeration date
02/27/2007
Last updated
08/25/2016
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