Provider Demographics
NPI:1285815399
Name:SERENITY NEUROPSYCHOLOGY, PLLC
Entity Type:Organization
Organization Name:SERENITY NEUROPSYCHOLOGY, PLLC
Other - Org Name:SERENITY NEUROPSYCHOLOGY & COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SNIDER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-957-5450
Mailing Address - Street 1:2498 N STOKESBERRY PL STE 150
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5150
Mailing Address - Country:US
Mailing Address - Phone:208-957-5450
Mailing Address - Fax:208-957-5292
Practice Address - Street 1:2498 N STOKESBERRY PL STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5150
Practice Address - Country:US
Practice Address - Phone:208-957-5450
Practice Address - Fax:208-957-5292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202392103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1982734984OtherINDIVIDUAL NPI
IDN6316OtherBLUE CROSS
ID000010162954OtherREGENCE BLUE SHIELD
ID16200124OtherMEDICARE GROUP PIN
IDN6316OtherBLUE CROSS