=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578712618
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL RIAL PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2008
-----------------------------------------------------
Last Update Date | 10/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 296 4TH ST # 934
-----------------------------------------------------
City | PONDERAY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83852-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-610-4682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 BIRCH GROVE DR
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-9125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-610-4682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 376
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY-202166
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------