Provider Demographics
NPI:1275891194
Name:DAVID E. NILSSON, PH.D., P.C.
Entity Type:Organization
Organization Name:DAVID E. NILSSON, PH.D., P.C.
Other - Org Name:THE NEURODEVELOPMENT RESOURCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:NILSSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-947-5368
Mailing Address - Street 1:950 W BANNOCK ST STE 1100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6140
Mailing Address - Country:US
Mailing Address - Phone:208-947-5368
Mailing Address - Fax:888-328-9210
Practice Address - Street 1:950 W BANNOCK ST STE 1100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6140
Practice Address - Country:US
Practice Address - Phone:208-947-5368
Practice Address - Fax:888-328-9210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-28
Last Update Date:2012-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-230103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty