Basic Information
| Provider Information | |||||||||
| NPI: | 1386914505 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROSSPOINTE MENTAL HEALTH, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CROSSPOINTE FAMILY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1363 FILLMORE ST | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367090 | ||||||||
| FaxNumber: | 2087367089 | ||||||||
| Practice Location | |||||||||
| Address1: | 1363 FILLMORE ST | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367090 | ||||||||
| FaxNumber: | 2087367089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2012 | ||||||||
| LastUpdateDate: | 05/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | NYLA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2087367090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | ID | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | ID | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | ID | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | ID | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 104100000X | ID | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | ID | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 261QP2300X | ID | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1235457565 | 05 | ID | MEDICAID |