Provider Demographics
NPI:1497565832
Name:SNAKE RIVER MENTAL HEALTH, PLLC
Entity type:Organization
Organization Name:SNAKE RIVER MENTAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:GREAVES
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:801-664-1757
Mailing Address - Street 1:15821 ALLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:ID
Mailing Address - Zip Code:83676-5864
Mailing Address - Country:US
Mailing Address - Phone:208-278-2863
Mailing Address - Fax:208-621-3128
Practice Address - Street 1:15821 ALLENDALE RD
Practice Address - Street 2:
Practice Address - City:WILDER
Practice Address - State:ID
Practice Address - Zip Code:83676-5864
Practice Address - Country:US
Practice Address - Phone:208-278-2863
Practice Address - Fax:208-621-3128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-08
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty