Healthcare Provider Details

I. General information

NPI: 1871672840
Provider Name (Legal Business Name): PSYCHOLOGICAL SERVICE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 E 25TH ST SUITE 290
IDAHO FALLS ID
83404-7519
US

IV. Provider business mailing address

PO BOX 3480
IDAHO FALLS ID
83403-3480
US

V. Phone/Fax

Practice location:
  • Phone: 208-525-2090
  • Fax: 208-525-2662
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-525-2662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-386
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT-2661
License Number StateID

VIII. Authorized Official

Name: HOWARD K HARPER
Title or Position: OWNER
Credential: PHD
Phone: 208-552-0490