Provider Demographics
NPI:1114321163
Name:MERIDIAN NEUROPSYCHOLOGY PLLC
Entity Type:Organization
Organization Name:MERIDIAN NEUROPSYCHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHWICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-895-9852
Mailing Address - Street 1:3061 S MERIDIAN RD
Mailing Address - Street 2:STE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7962
Mailing Address - Country:US
Mailing Address - Phone:208-895-9852
Mailing Address - Fax:208-629-1231
Practice Address - Street 1:3061 S MERIDIAN RD
Practice Address - Street 2:STE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7962
Practice Address - Country:US
Practice Address - Phone:208-895-9852
Practice Address - Fax:208-629-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202728103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty