Organization
IDAHO DEPT OF HEALTH & WELFARE REGION 7 AMH PSR IF
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MELISSA M BEAN MA (PROGRAM MANAGER)
(208) 528-5706
Entity
Organization
Contact information
Practice address
150 SHOUP AVE, SUITE 17, IDAHO FALLS, ID 83402-3657
(208) 528-5700
(208) 528-5747
Mailing address
150 SHOUP AVE, SUITE 17, IDAHO FALLS, ID 83402-3657
(208) 528-5700
(208) 528-5747
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
—
000010019479
BLUE SHIELD
—
05
—
0028410
—
ID
01
—
HW181
BLUE CROSS OF IDAHO
—
Enumeration date
02/26/2007
Last updated
08/22/2020
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