Basic Information
Provider Information | |||||||||
NPI: | 1376850990 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIDVALLEY HEALTHCARE PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MIDVALLEY HEALTHCARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2321 E GALA ST STE 3 | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | ID | ||||||||
PostalCode: | 836427692 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088885848 | ||||||||
FaxNumber: | 2083239070 | ||||||||
Practice Location | |||||||||
Address1: | 2321 E GALA ST STE 3 | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | ID | ||||||||
PostalCode: | 836427692 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083239130 | ||||||||
FaxNumber: | 2083239070 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/02/2010 | ||||||||
LastUpdateDate: | 11/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRINGTON | ||||||||
AuthorizedOfficialFirstName: | KRISTINA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
AuthorizedOfficialTelephone: | 2088885848 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 11/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP2701X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
No ID Information.