Healthcare Provider Details

I. General information

NPI: 1053348441
Provider Name (Legal Business Name): CLAY HEROLD WARD PH.D. CLINICAL PSYCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3061 S MERIDIAN RD SUITE 150
MERIDIAN ID
83642-7962
US

IV. Provider business mailing address

P.O. BOX 465
KUNA ID
83634
US

V. Phone/Fax

Practice location:
  • Phone: 208-631-5063
  • Fax: 208-887-0950
Mailing address:
  • Phone: 208-631-5063
  • Fax: 208-887-0950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY239
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY239
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-239
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: