Healthcare Provider Details

I. General information

NPI: 1285815399
Provider Name (Legal Business Name): SERENITY NEUROPSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2498 N STOKESBERRY PL STE 150
MERIDIAN ID
83646-5150
US

IV. Provider business mailing address

2498 N STOKESBERRY PL STE 150
MERIDIAN ID
83646-5150
US

V. Phone/Fax

Practice location:
  • Phone: 208-957-5450
  • Fax: 208-957-5292
Mailing address:
  • Phone: 208-957-5450
  • Fax: 208-957-5292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-202392
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY-202392
License Number StateID

VIII. Authorized Official

Name: DR. MELODY LYNN SNIDER
Title or Position: LICENSED PSYCHOLOGIST/OWNER
Credential: PHD
Phone: 208-957-5450