NPIMap

Organization Active NPI

Portneuf Valley Family Center

  • Professional Counselor
  • Pocatello, ID
National Provider Identifier
1174629976
Registry record updated Jun 27, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Professional CounselorTaxonomy code 101YP2500X
Legal business name
PORTNEUF VALLEY FAMILY CENTER
Practice address
444 Hospital Way Ste 477
Pocatello, ID 83201-2744
Phone
(208) 233-7832
Fax
(208) 233-7835
NPI assigned
Sep 16, 2006
Last updated
Jun 27, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 27, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Robert De WallNPI 1114228384
Title
Owner/Administrator
Phone
(208) 233-7832

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101Y00000X
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X
Professional CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YP2500X Primary
Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 104100000X
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X

Addresses

Primary practice location

444 Hospital Way Ste 477
Pocatello, ID 83201-2744

Mailing address

444 Hospital Way Ste 477
Pocatello, ID 83201-2744
Phone (208) 233-7832

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070122000564 ID Part B Supplier - Clinic/Group Practice 6901807718 Receives reassigned benefits from 13 practitioners
Practice locations: Pocatello, ID; Soda Springs, ID

National Provider Directory

National Provider Directory
Tax ID family
Portneuf Valley Family Center4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

15 W Center St
Ste 2
Soda Springs, ID 83276
Phone (208) 547-4470

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 21

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1158364800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750982400000",
    "number": "1174629976",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "444 HOSPITAL WAY STE 477",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832012744",
            "telephone_number": "208-233-7832",
            "fax_number": "208-233-7835"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "444 HOSPITAL WAY STE 477",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832012744",
            "telephone_number": "208-233-7832",
            "fax_number": "208-233-7835"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PORTNEUF VALLEY FAMILY CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-16",
        "last_updated": "2025-06-27",
        "certification_date": "2025-06-27",
        "status": "A",
        "authorized_official_last_name": "DE WALL",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_title_or_position": "OWNER/ADMINISTRATOR",
        "authorized_official_telephone_number": "208-233-7832"
    },
    "taxonomies": [
        {
            "code": "101Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "104100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Pocatello, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.