1528714144 NPI number — IDAHO COUNSELING AND NEUROFEEDBACK

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528714144 NPI number — IDAHO COUNSELING AND NEUROFEEDBACK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDAHO COUNSELING AND NEUROFEEDBACK
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:
1528714144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2650 S EAGLE RD STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-6745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3348 E GOLDSTONE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-1026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-571-2210
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2022

Additional Information

Authorized Official

Authorized Official Last Name:
KATSEANES
Authorized Official First Name:
LOGAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-866-4688

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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