Healthcare Provider Details

I. General information

NPI: 1568766566
Provider Name (Legal Business Name): NORTHWEST NEUROBEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2011
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 E MAGIC VIEW DR STE 140
MERIDIAN ID
83642-9273
US

IV. Provider business mailing address

2950 E MAGIC VIEW DR STE 140
MERIDIAN ID
83642-9273
US

V. Phone/Fax

Practice location:
  • Phone: 208-323-9130
  • Fax: 208-323-9070
Mailing address:
  • Phone: 208-323-9130
  • Fax: 208-323-9070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY-202444
License Number StateID

VIII. Authorized Official

Name: JEREMY EVANS
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 208-323-9130