Provider Demographics
NPI:1174682959
Name:IDAHO STATE UNIVERSITY, PSYCHOLOGY CLINIC
Entity Type:Organization
Organization Name:IDAHO STATE UNIVERSITY, PSYCHOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PSYCH CLINIC
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CELLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-282-2129
Mailing Address - Street 1:ISU PSYCHOLOGY CLINIC IDAHO STATE UNIVERSITY
Mailing Address - Street 2:921 S. 8TH AVENUE, STOP 8021
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0001
Mailing Address - Country:US
Mailing Address - Phone:208-282-2129
Mailing Address - Fax:208-282-5411
Practice Address - Street 1:ISU PSYCHOLOGY CLINIC IDAHO STATE UNIVERSITY
Practice Address - Street 2:921 S. 8TH AVENUE, STOP 8021
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-2129
Practice Address - Fax:208-282-5411
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-07
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID344251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health