Provider Demographics
NPI:1245665470
Name:BANNOCK YOUTH FOUNDATION
Entity type:Organization
Organization Name:BANNOCK YOUTH FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:208-234-4722
Mailing Address - Street 1:P.O. BOX 246
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204
Mailing Address - Country:US
Mailing Address - Phone:208-234-4722
Mailing Address - Fax:208-234-2135
Practice Address - Street 1:110 SOUTH 19TH
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-234-4722
Practice Address - Fax:208-234-2135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNOCK YOUTH FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty