Healthcare Provider Details

I. General information

NPI: 1952443640
Provider Name (Legal Business Name): CHRISTINE PICKFORD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 N 18TH ST
BOISE ID
83702-3321
US

IV. Provider business mailing address

1104 N 18TH ST
BOISE ID
83702-3321
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-3131
  • Fax:
Mailing address:
  • Phone: 208-342-3131
  • Fax: 208-383-0329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number120
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number120
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number120
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number120
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number120
License Number StateID
# 6
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number120
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: