Basic Information
| Provider Information | |||||||||
| NPI: | 1316251895 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEASONS OF HOPE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4650 HAWTHORNE RD | ||||||||
| Address2: | SUITE 3B | ||||||||
| City: | CHUBBUCK | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832022376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082379833 | ||||||||
| FaxNumber: | 2082371800 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 HAWTHORNE RD | ||||||||
| Address2: | SUITE 3B | ||||||||
| City: | CHUBBUCK | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832022376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082379833 | ||||||||
| FaxNumber: | 2082371800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2010 | ||||||||
| LastUpdateDate: | 09/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | SOMMER | ||||||||
| AuthorizedOfficialFirstName: | HEATH | ||||||||
| AuthorizedOfficialMiddleName: | JACOB | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2082379833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | PSY202423 | ID | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1376865006 | 05 | ID | MEDICAID |