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General NPI Number Information
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NPI Number | 1114321163
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Entity Type | Organization
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Legal Business Name | MERIDIAN NEUROPSYCHOLOGY PLLC
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Dates
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Enumeration Date | 10/20/2014
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Last Update Date | 05/18/2024
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Provider Practice Location Address
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Address Line | 3061 S MERIDIAN RD STE 100
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City | MERIDIAN
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State | ID
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Zip | 83642-7962
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Country | US
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Telephone | 208-895-9852
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Fax | 208-629-1231
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Provider Business Mailing Address
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Address Line | 3597 E MONARCH SKY LN STE 240
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City | MERIDIAN
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State | ID
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Zip | 83646-1055
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Country | US
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Telephone | 208-391-7274
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Fax | 208-629-1231
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Authorized Official
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Title or Position | MANAGER
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Name | DR. JASON SOUTHWICK
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Credential | PHD
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Telephone | 208-895-9852
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY-202728
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | PSY-202728
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License Number State | ID
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