Provider Demographics
NPI:1528136793
Name:PSYCHIATRIC SERVICES, PA
Entity type:Organization
Organization Name:PSYCHIATRIC SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-732-0995
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0047
Mailing Address - Country:US
Mailing Address - Phone:208-732-0995
Mailing Address - Fax:208-732-0993
Practice Address - Street 1:493 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-7480
Practice Address - Country:US
Practice Address - Phone:208-732-0995
Practice Address - Fax:208-732-0993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM53712084P0800X
IDLMFT-26872084P0800X
IDLPC33812084P0800X
IDPA4992084P0800X
IDLCPC34332084P0800X
IDCNS122084P0800X
IDLCPC34042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010028578OtherBLUSHILD GROUP
ID000010028578OtherBLUSHILD GROUP
ID1375257Medicare ID - Type UnspecifiedALL PROVIDERS MEDICARE GR