Healthcare Provider Details

I. General information

NPI: 1861759854
Provider Name (Legal Business Name): EPIC PSYCHOLOGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2273 E GALA ST SUITE 100
MERIDIAN ID
83642-7289
US

IV. Provider business mailing address

24108 TEN DAVIS RD
PARMA ID
83660-7212
US

V. Phone/Fax

Practice location:
  • Phone: 208-898-8999
  • Fax: 208-898-8989
Mailing address:
  • Phone: 208-898-8999
  • Fax: 208-898-8989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-282
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-282
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY-282
License Number StateID

VIII. Authorized Official

Name: DR. RYAN J HULBERT
Title or Position: OWNER
Credential: PH.D.
Phone: 208-898-8999