Organization
TELEMENTAL HEALTH LINK LLC
Active
Parent organization
PSYCHIATRIC NURSE PRACTITIONER SERVICES LLC
Other names
Psychiatric Nurse Practitioner Services LLC, TELEMENTAL HEALTH LINK - NM
Organization subpart
Yes
Provider details
NPI number
Legal business name
PSYCHIATRIC NURSE PRACTITIONER SERVICES LLC
Authorized official
SUSAN M DERIVAS PMHNP-BC (AO)
(208) 775-7418
Entity
Organization
Contact information
Practice address
4055 E BLUEBERRY ST, MERIDIAN, ID 83642-8261
(208) 775-7418
(208) 647-5008
Mailing address
4055 E BLUEBERRY ST, MERIDIAN, ID 83642-8261
(208) 600-2060
(208) 647-5008
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
020837
—
ID
01
—
0364158
ANCC CERTIFICATION NO.
—
01
—
03962
NURSING LICENSE
LA
01
—
13961493
CAQH ID
—
01
—
1529234
NCSBN ID
—
01
—
363LP0808X
TAXONOMIES: NURSE PRACTITIONER PSYCH MENTAL HEALTH
LA
01
—
396453OSMIND
CHANGE HEALTHCARE MASTER BILLING ID
—
01
—
58322
NURSING LICENSE
NM
01
—
64266
NURSING LICENSE
ID
01
—
P69441
UPIN
LA
Enumeration date
02/27/2020
Last updated
02/07/2024
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