Basic Information
| Provider Information | |||||||||
| NPI: | 1235401522 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SNAKE RIVER COUNSELING CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2635 CHANNING WAY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085520490 | ||||||||
| FaxNumber: | 2085522518 | ||||||||
| Practice Location | |||||||||
| Address1: | 2635 CHANNING WAY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085520490 | ||||||||
| FaxNumber: | 2085522518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2012 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | POPEJOY | ||||||||
| AuthorizedOfficialFirstName: | JULI | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2085252090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.