MEDICARE: DR. CLAY HEROLD WARD PH.D. CLINICAL PSYCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PSY239	ID
2	103T00000X	Psychologist	PSY239	ID
3	103T00000X	Psychologist	PSY-239	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00001001591	OTHER	ID	REGENCE BLUE SHIELD
2	1598959322	OTHER		GROUP NPI
3	N2399	OTHER	ID	BLUE CROSS

General Provider Information

NPI Number	:	1053348441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLAY HEROLD WARD PH.D. CLINICAL PSYCH

Provider Business Mailing Address
First Line	:	P.O. BOX 465
Second Line	:
City	:	KUNA
State	:	ID
Zip	:	83634
Country	:	US
Telephone Number	:	208-631-5063
Fax Number	:	208-887-0950

Provider Business Practice Location Address
First Line	:	3061 S MERIDIAN RD
Second Line	:	SUITE 150
City	:	MERIDIAN
State	:	ID
Zip	:	83642-7962
Country	:	US
Telephone Number	:	208-631-5063
Fax Number	:	208-887-0950

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	11/13/2012

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