| Organization Name: | IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH PSR CDA |
| NPI Number: | 1023145893 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | CORA JO GUSSENHOVEN (PROGRAM MANAGER) |
| Mailing Address: | 2195 Ironwood Ct Coeur D Alene |
| State: | ID US |
| Postal Code: | 838142628 |
| Phone Number: | 2087691406 |
| Fax Number: | 2087691430 |
| NPI Enumeration Date: | 02/27/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QM0801X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Mental Health (Including Community Mental Health Center) |
| Taxonomy Definition: | |