| Idaho State University | |
|
1400 E Terry Dr Bldg 63 Pocatello ID 83209-0001 | |
| (208) 240-1690 | |
| Not Available |
| Full Name | Idaho State University |
|---|---|
| Speciality | Counselor - Mental Health |
| Location | 1400 E Terry Dr Bldg 63, Pocatello, Idaho |
| Authorized Official Name and Position | Cynthia Lee Rock (CLINICS DIRECTOR OF OPERATIONS) |
| Authorized Official Contact | 2083731743 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Idaho State University 921 S 8th Ave Stop 8120 Pocatello ID 83209-0002 Ph: (208) 240-1609 | Idaho State University 1400 E Terry Dr Bldg 63 Pocatello ID 83209-0001 Ph: (208) 240-1690 |
| NPI Number | 1811595929 |
|---|---|
| Provider Enumeration Date | 10/12/2020 |
| Last Update Date | 10/12/2020 |
| Certification Date | 10/12/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811595929 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
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