Provider Demographics
NPI:1043057359
Name:REKINDLED SPIRIT MARSHALL MENTAL HEALTH
Entity type:Organization
Organization Name:REKINDLED SPIRIT MARSHALL MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:082-901-6691
Mailing Address - Street 1:4614 N SAVANNAH LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-7405
Mailing Address - Country:US
Mailing Address - Phone:208-901-6691
Mailing Address - Fax:
Practice Address - Street 1:413 N ALLUMBAUGH ST STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9219
Practice Address - Country:US
Practice Address - Phone:208-323-1125
Practice Address - Fax:208-323-9604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-12
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty