Basic Information
| Provider Information | |||||||||
| NPI: | 1679796007 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLIANCE FAMILY SERVICES NORTH, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 S DIVISION AVE | ||||||||
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| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838641749 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 W MOANA LN | ||||||||
| Address2: | SUITE 14 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895094775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753372394 | ||||||||
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| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 02/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | LANGE | ||||||||
| AuthorizedOfficialFirstName: | TRACEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2082655049 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 2084P0804X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 261QD1600X | N | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 100509368 | 05 | NV | MEDICAID | 100511714 | 05 | NV | MEDICAID | 100509367 | 05 | NV | MEDICAID |