Healthcare Provider Details

I. General information

NPI: 1326084492
Provider Name (Legal Business Name): J. MICHAEL DENNIS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N. ALLUMBAUGH ST.
BOISE ID
83704
US

IV. Provider business mailing address

311 N. ALLUMBAUGH ST.
BOISE ID
83704
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-6402
  • Fax: 208-323-1850
Mailing address:
  • Phone: 208-375-6402
  • Fax: 208-323-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY371
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: