Provider Demographics
NPI:1235148131
Name:HAVILAND, VIRGINIA PAGE (PHD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:PAGE
Last Name:HAVILAND
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:4424 E FLAMINGO AVE STE 310
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9306
Practice Address - Country:US
Practice Address - Phone:208-302-3760
Practice Address - Fax:208-302-3768
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY 292103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID76372OtherBLUE CROSS OF IDAHO
ID000010153284OtherREGENCE BLUE SHIELD OF ID
ID203644829OtherTAX I.D. NUMBER