Provider Demographics
NPI:1043368418
Name:MOUNTAIN STATES CHEMICAL DEPENDENCY AND COUNSELING SERVICES, INC.
Entity type:Organization
Organization Name:MOUNTAIN STATES CHEMICAL DEPENDENCY AND COUNSELING SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSTY
Authorized Official - Middle Name:
Authorized Official - Last Name:O'LEARY
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:208-463-0202
Mailing Address - Street 1:1305 2ND ST SOUTH
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3964
Mailing Address - Country:US
Mailing Address - Phone:208-463-0202
Mailing Address - Fax:208-463-0205
Practice Address - Street 1:1305 2ND ST S
Practice Address - Street 2:SUITE 201
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3944
Practice Address - Country:US
Practice Address - Phone:208-463-0202
Practice Address - Fax:208-463-0205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806878800Medicaid
ID806892300Medicaid
ID807126800Medicaid