Provider Demographics
NPI:1548001522
Name:MOUNTAIN LAUREL THERAPY LLC
Entity type:Organization
Organization Name:MOUNTAIN LAUREL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:OVERACRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-308-6764
Mailing Address - Street 1:1011 BELL LN
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:ID
Mailing Address - Zip Code:83341-5182
Mailing Address - Country:US
Mailing Address - Phone:910-308-6764
Mailing Address - Fax:
Practice Address - Street 1:133 MAIN AVE W
Practice Address - Street 2:SUITE 300
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:910-308-6764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty