Basic Information
| Provider Information | |||||||||
| NPI: | 1043751175 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SECOND WIND COUNSELING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7621 W WAVERLY DR | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837047210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 1423 W FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837025024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083452212 | ||||||||
| FaxNumber: | 2083452282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2017 | ||||||||
| LastUpdateDate: | 03/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | MAHANA | ||||||||
| AuthorizedOfficialFirstName: | LONNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2082879420 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LCPC-3442 | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | LCPC-3442 | 01 | ID | STATE LICENSE | OTHER |