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General NPI Number Information
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NPI Number | 1174682959
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Entity Type | Organization
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Legal Business Name | IDAHO STATE UNIVERSITY, PSYCHOLOGY CLINIC
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Dates
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Enumeration Date | 12/07/2006
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Last Update Date | 06/17/2008
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Provider Practice Location Address
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Address Line | ISU PSYCHOLOGY CLINIC IDAHO STATE UNIVERSITY 921 S. 8TH AVENUE, STOP 8021
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City | POCATELLO
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State | ID
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Zip | 83209-0001
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Country | US
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Telephone | 208-282-2129
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Fax | 208-282-5411
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Provider Business Mailing Address
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Address Line | ISU PSYCHOLOGY CLINIC IDAHO STATE UNIVERSITY 921 S. 8TH AVENUE, STOP 8021
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City | POCATELLO
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State | ID
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Zip | 83209-0001
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Country | US
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Telephone | 208-282-2129
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Fax | 208-282-5411
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Authorized Official
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Title or Position | DIRECTOR OF PSYCH CLINIC
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Name | DR. ANTHONY J. CELLUCCI
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Credential | PH.D.
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Telephone | 208-282-2129
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 344
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License Number State | ID
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