| Lake City Counseling Center Llc | |
|
9705 N Shaw St Hayden ID 83835-9716 | |
| (208) 625-9981 | |
| Not Available |
| Full Name | Lake City Counseling Center Llc |
|---|---|
| Speciality | Social Worker |
| Location | 9705 N Shaw St, Hayden, Idaho |
| Authorized Official Name and Position | Jennifer Rian Tuttle (OWNER) |
| Authorized Official Contact | 2088192716 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lake City Counseling Center Llc 9705 N Shaw St Hayden ID 83835-9716 Ph: (208) 819-2716 | Lake City Counseling Center Llc 9705 N Shaw St Hayden ID 83835-9716 Ph: (208) 625-9981 |
| NPI Number | 1720513963 |
|---|---|
| Provider Enumeration Date | 04/25/2017 |
| Last Update Date | 07/06/2020 |
| Certification Date | 07/06/2020 |
| Medicare PECOS PAC ID | 3779904503 |
|---|---|
| Medicare Enrollment ID | O20200819001200 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1720513963 | NPI | - | NPPES |
| IDTPID013454 | Medicaid | ID |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
| Provider Name | Jennifer Rian Tuttle |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1609158781 PECOS PAC ID: 2365619335 Enrollment ID: I20120113000439 |
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