NPIMap

Organization Active NPI

Regents of the University of Idaho Child & Youth Study Center

Doing business as Child & Youth Study Center

  • Clinical Child & Adolescent Psychologist
  • Moscow, ID
National Provider Identifier
1609902980
Registry record updated Apr 1, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Child & Adolescent PsychologistTaxonomy code 103TC2200X
Legal business name
REGENTS OF THE UNIVERSITY OF IDAHO CHILD & YOUTH STUDY CENTER
Doing business as
Child & Youth Study Center
Practice address
121 West Sweet Avenue
Moscow, ID 83843
Phone
(208) 885-6191
Fax
(208) 885-6188
NPI assigned
Feb 23, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 1, 2014

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

Authorized official

Name
Dr. Gwen Elaine Mitchell, LPC, NCSP
Title
Director
Phone
(208) 885-6191

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Child & Adolescent PsychologistGroup: 193400000X SINGLE SPECIALTY GROUP 103TC2200X Primary

Addresses

Primary practice location

121 West Sweet Avenue
Moscow, ID 83843

Mailing address

875 Perimeter Drive
Ms 4061
Moscow, ID 83844-4061
Phone (208) 885-3588

Other identifiers 1

IdentifierTypeStateIssuer
807220700MedicaidID

Other names 1

  • Child & Youth Study Center Doing business as

National Provider Directory

National Provider Directory
Tax ID family
CDHD Behavioral Consultants4 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

121 W Sweet Ave
Moscow, ID 83843
Phone (208) 885-6191

875 Perimeter Dr
#4061
Moscow, ID 83844

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1172188800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1396310400000",
    "number": "1609902980",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "875 PERIMETER DRIVE",
            "address_2": "MS 4061",
            "city": "MOSCOW",
            "state": "ID",
            "postal_code": "838444061",
            "telephone_number": "208-885-3588",
            "fax_number": "208-885-3536"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "121 WEST SWEET AVENUE",
            "city": "MOSCOW",
            "state": "ID",
            "postal_code": "83843",
            "telephone_number": "208-885-6191",
            "fax_number": "208-885-6188"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REGENTS OF THE UNIVERSITY OF IDAHO CHILD & YOUTH STUDY CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-23",
        "last_updated": "2014-04-01",
        "status": "A",
        "authorized_official_last_name": "MITCHELL",
        "authorized_official_first_name": "GWEN",
        "authorized_official_middle_name": "ELAINE",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "208-885-6191",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "LPC, NCSP"
    },
    "taxonomies": [
        {
            "code": "103TC2200X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist, Clinical Child & Adolescent",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "807220700",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Child & Youth Study Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Moscow, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 1, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.