Basic Information
| Provider Information | |||||||||
| NPI: | 1215359856 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEQUEL ALLIANCE FAMILY SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1131 EAGLETREE LN SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358016478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568803339 | ||||||||
| FaxNumber: | 2568809569 | ||||||||
| Practice Location | |||||||||
| Address1: | 89 HOMER DR | ||||||||
| Address2: | |||||||||
| City: | ST MARIES | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838615078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082455427 | ||||||||
| FaxNumber: | 2082455427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2014 | ||||||||
| LastUpdateDate: | 01/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | CAUDLE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CBO DIRECTOR OF PATIENT ACCOUNTS | ||||||||
| AuthorizedOfficialTelephone: | 2568803339 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SEQUEL TSI HOLDING, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | W132383 | 01 | STATE LICENSE NUMBER | OTHER |