=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760086300
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEARWATER NEUROSCIENCES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2020
-----------------------------------------------------
Last Update Date | 11/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3326 4TH ST STE 6
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501-4455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-746-2223
-----------------------------------------------------
Fax | 208-746-2226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3326 4TH ST STE 6
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501-4455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-746-2223
-----------------------------------------------------
Fax | 208-746-2226
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. GAIL RICHARDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-746-2223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------