1104102375 NPI number — CALICO PEDIATRIC THERAPY CENTER, LLC

Table of content: LINDA (LIN) ANN REAMS MA, LPCC (NPI 1649932740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104102375 NPI number — CALICO PEDIATRIC THERAPY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALICO PEDIATRIC THERAPY CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104102375
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4145 WILLOW CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGLE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83616-2505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-850-5804
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 N HILTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83706-1734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-850-5804
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
NEGILSKI
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-850-5804

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP-1396 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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