Healthcare Provider Details

I. General information

NPI: 1750257184
Provider Name (Legal Business Name): IDAHO NEUROPSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 S FIVE MILE RD
BOISE ID
83709-1306
US

IV. Provider business mailing address

10400 W OVERLAND RD # 357
BOISE ID
83709-1433
US

V. Phone/Fax

Practice location:
  • Phone: 208-789-0910
  • Fax: 208-789-0916
Mailing address:
  • Phone: 208-789-0910
  • Fax: 208-789-0916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH S BLACK
Title or Position: OWNER/CEO
Credential: PHD, ABN
Phone: 208-207-8331