Basic Information
| Provider Information | |||||||||
| NPI: | 1053536524 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY SUPPORT SERVICES OF NORTH IDAHO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 W IRONWOOD DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087694222 | ||||||||
| FaxNumber: | 2086677557 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 W IRONWOOD DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087694222 | ||||||||
| FaxNumber: | 2086677557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JODI | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2087694222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.ED | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | ID | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.