Basic Information
| Provider Information | |||||||||
| NPI: | 1811389299 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROSSPOINTE MENTAL HEALTH, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CROSSPOINTE FAMILY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 FILLMORE STREET | ||||||||
| Address2: | SUITE 702 AND 703 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367090 | ||||||||
| FaxNumber: | 2087367089 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 FILLMORE ST | ||||||||
| Address2: | SUITE 702 & 703 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367090 | ||||||||
| FaxNumber: | 2087367089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2015 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | NYLA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2087367090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | Y | Agencies | Day Training, Developmentally Disabled Services |
ID Information
| ID | Type | State | Issuer | Description | 1386914505 | 05 | ID | MEDICAID |