Healthcare Provider Details

I. General information

NPI: 1225176498
Provider Name (Legal Business Name): CRAIG W. BEAVER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BOBWHITE CT STE 220
BOISE ID
83706-3983
US

IV. Provider business mailing address

250 BOBWHITE CT STE 220
BOISE ID
83706-3983
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-2972
  • Fax: 208-336-4408
Mailing address:
  • Phone: 208-336-2972
  • Fax: 208-336-4408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY-173
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: