Healthcare Provider Details

I. General information

NPI: 1780010090
Provider Name (Legal Business Name): PSYCHOLOGY CENTER OF IDAHO FALLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 S 25TH E STE 2
IDAHO FALLS ID
83404-4956
US

IV. Provider business mailing address

3670 S 25TH E STE 2
IDAHO FALLS ID
83404-4956
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-3404
  • Fax: 208-524-1093
Mailing address:
  • Phone: 208-522-3404
  • Fax: 208-524-1093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number202288
License Number StateID

VIII. Authorized Official

Name: DR. CAROL VERNON ANDERSON
Title or Position: PRESIDENT, CLIICAL NEUROPSYCHOLOGIS
Credential: PH.D. ABPP-CN
Phone: 208-522-3404