Healthcare Provider Details

I. General information

NPI: 1043370372
Provider Name (Legal Business Name): NICHOLAS E. HEYNEMAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E CENTER ST SUITE A
POCATELLO ID
83201-5737
US

IV. Provider business mailing address

24 YALE ST
POCATELLO ID
83201-3436
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-7740
  • Fax: 208-392-1541
Mailing address:
  • Phone: 208-234-7740
  • Fax: 208-392-1541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-234
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: