Provider Demographics
NPI:1225176498
Name:BEAVER, CRAIG W (PHD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:W
Last Name:BEAVER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 BOBWHITE CT STE 220
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3983
Mailing Address - Country:US
Mailing Address - Phone:208-336-2972
Mailing Address - Fax:208-336-4408
Practice Address - Street 1:250 BOBWHITE CT STE 220
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3983
Practice Address - Country:US
Practice Address - Phone:208-336-2972
Practice Address - Fax:208-336-4408
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-173103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010016209OtherBLUE SHIELD
IDN1730OtherBLUE CROSS
ID1680626Medicare ID - Type Unspecified