Basic Information
Provider Information | |||||||||
NPI: | 1932499738 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALLIANCE FAMILY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 608 S DIVISION AVE | ||||||||
Address2: |   | ||||||||
City: | SANDPOINT | ||||||||
State: | ID | ||||||||
PostalCode: | 838641749 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082658195 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 186 E MAIN ST STE 4 | ||||||||
Address2: |   | ||||||||
City: | FERNLEY | ||||||||
State: | NV | ||||||||
PostalCode: | 894087717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7755759889 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2011 | ||||||||
LastUpdateDate: | 04/13/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LANGE | ||||||||
AuthorizedOfficialFirstName: | TRACEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2082658195 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 251C00000X |   |   | N |   | Agencies | Day Training, Developmentally Disabled Services |   | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QM0850X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 101YM0800X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.