=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285815399
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY NEUROPSYCHOLOGY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2007
-----------------------------------------------------
Last Update Date | 01/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2498 N STOKESBERRY PL STE 150
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-5150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-957-5450
-----------------------------------------------------
Fax | 208-957-5292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2498 N STOKESBERRY PL STE 150
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-5150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-957-5450
-----------------------------------------------------
Fax | 208-957-5292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST/OWNER
-----------------------------------------------------
Name | DR. MELODY LYNN SNIDER
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 208-957-5450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY-202392
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PSY-202392
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------