Organization
SOUTH FORK SERVICES, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WADE GORDON LCSW (OWNER)
(208) 356-5675
Entity
Organization
Contact information
Practice address
310 N 2ND E STE 128, REXBURG, ID 83440-1607
(208) 356-5675
Mailing address
310 N 2ND E STE 128, REXBURG, ID 83440-1607
(208) 356-5675
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
LCSW 27205
ID
Other
Enumeration date
07/23/2013
Last updated
07/23/2013
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