MEDICARE: MICHAEL MCCLAY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY 240	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	083361	OTHER	ID	REGENCE BLUE SHIELD PIN
2	N-2407	OTHER	ID	BLUE CROSS OF IDAHO PIN

General Provider Information

NPI Number	:	1356364111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL MCCLAY PH.D.

Provider Business Mailing Address
First Line	:	582 E BOISE AVE
Second Line	:	PMB 222
City	:	BOISE
State	:	ID
Zip	:	83706-5116
Country	:	US
Telephone Number	:	208-489-4040
Fax Number	:	208-489-4064

Provider Business Practice Location Address
First Line	:	600 ROBBINS RD
Second Line	:	SUITE 101
City	:	BOISE
State	:	ID
Zip	:	83702-4539
Country	:	US
Telephone Number	:	208-489-4040
Fax Number	:	208-489-4064

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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