Healthcare Provider Details

I. General information

NPI: 1154665123
Provider Name (Legal Business Name): MERRY SYLVESTER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

1055 N CURTIS RD
BOISE ID
83706-1309
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-2696
  • Fax:
Mailing address:
  • Phone: 208-367-2696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY202628
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: