Basic Information
| Provider Information | |||||||||
| NPI: | 1679860746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYRINGA PSYCHOTHERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 N 1ST AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838641436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089465242 | ||||||||
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| Practice Location | |||||||||
| Address1: | 212 N 1ST AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838641436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089465242 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2011 | ||||||||
| LastUpdateDate: | 07/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | RICHMAN | ||||||||
| AuthorizedOfficialFirstName: | CLARK | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2089465242 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | LPC-4235 | ID | N | Agencies | Community/Behavioral Health | 251S00000X | LCPC-4465 | ID | Y | Agencies | Community/Behavioral Health |
No ID Information.