Healthcare Provider Details

I. General information

NPI: 1275891194
Provider Name (Legal Business Name): DAVID E. NILSSON, PH.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2012
Last Update Date: 04/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 W BANNOCK ST STE 1100
BOISE ID
83702-6140
US

IV. Provider business mailing address

950 W BANNOCK ST STE 1100
BOISE ID
83702-6140
US

V. Phone/Fax

Practice location:
  • Phone: 208-947-5368
  • Fax: 888-328-9210
Mailing address:
  • Phone: 208-947-5368
  • Fax: 888-328-9210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY-230
License Number StateID

VIII. Authorized Official

Name: CINDY NILSSON
Title or Position: CLINIC DIRECTOR
Credential: PT
Phone: 208-947-5368