Basic Information
| Provider Information | |||||||||
| NPI: | 1821388505 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TW MCKNIGHT ENTERPRISES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LIFESPAN FAMILY PRACTICE MENTAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 POLK ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367090 | ||||||||
| FaxNumber: | 2087367089 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 POLK ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367090 | ||||||||
| FaxNumber: | 2087367089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2011 | ||||||||
| LastUpdateDate: | 04/14/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCKNIGHT | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2087367090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | ID | MEDICAID |