1437783529 NPI number — TELEMENTAL HEALTH LINK LLC

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 1437783529 NPI number — TELEMENTAL HEALTH LINK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TELEMENTAL HEALTH LINK 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:
PSYCHIATRIC NURSE PRACTITIONER SERVICES LLC
Provider Other Organization Name Type Code:
4
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:
1437783529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4055 E BLUEBERRY ST
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:
83642-8261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-600-2060
Provider Business Mailing Address Fax Number:
208-647-5008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4055 E BLUEBERRY ST
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:
83642-8261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-775-7418
Provider Business Practice Location Address Fax Number:
208-647-5008
Provider Enumeration Date:
02/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
DERIVAS
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
AO
Authorized Official Telephone Number:
208-775-7418

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 396453OSMIND . This is a "CHANGE HEALTHCARE MASTER BILLING ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 58322 . This is a "NURSING LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 58322 . This is a "NEW MEXICO APRN CNP LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 020837 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13961493 . This is a "CAQH ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64266 . This is a "NURSING LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 03962 . This is a "NURSING LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1529234 . This is a "NCSBN ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0364158 . This is a "ANCC CERTIFICATION NO." identifier . This identifiers is of the category "OTHER".
  • Identifier: 363LP0808X . This is a "TAXONOMIES: NURSE PRACTITIONER PSYCH MENTAL HEALTH" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: P69441 . This is a "UPIN" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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