Healthcare Provider Details

I. General information

NPI: 1720451230
Provider Name (Legal Business Name): MELISSA GRYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1276 W RIVER ST
BOISE ID
83702-7066
US

IV. Provider business mailing address

PO BOX 8516
BOISE ID
83707-2516
US

V. Phone/Fax

Practice location:
  • Phone: 208-338-4699
  • Fax:
Mailing address:
  • Phone: 208-703-4750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: