Provider Demographics
NPI:1346974359
Name:CLERICO, MEADOW MARIE (MA)
Entity Type:Individual
Prefix:
First Name:MEADOW
Middle Name:MARIE
Last Name:CLERICO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2463 E GALA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5210
Mailing Address - Country:US
Mailing Address - Phone:208-955-7339
Mailing Address - Fax:208-955-7330
Practice Address - Street 1:2463 E GALA ST STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5210
Practice Address - Country:US
Practice Address - Phone:208-955-7339
Practice Address - Fax:208-955-7330
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YM0800X, 390200000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program