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General NPI Number Information
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NPI Number | 1508100876
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Entity Type | Organization
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Legal Business Name | BIG LAKE PSYCHOLOGICAL SERVICES, PC
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Dates
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Enumeration Date | 11/26/2012
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Last Update Date | 07/27/2020
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Provider Practice Location Address
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Address Line | 1809 E SHERMAN AVE
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City | COEUR D ALENE
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State | ID
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Zip | 83814-5873
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Country | US
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Telephone | 208-665-9611
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Fax |
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Provider Business Mailing Address
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Address Line | 1104 W IRONWOOD DR
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2605
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Country | US
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Telephone | 208-550-3165
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Fax |
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Authorized Official
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Title or Position | CHIEF PSYCHOLOGIST
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Name | DR. HEATHER REHIL
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Credential | PSY.D.
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Telephone | 208-550-3165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | PSY-202671
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License Number State | ID
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