Provider Demographics
NPI:1467136523
Name:STARLIGHT PSYCHOLOGICAL SERVICES PLLC
Entity Type:Organization
Organization Name:STARLIGHT PSYCHOLOGICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WASILEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:347-515-5039
Mailing Address - Street 1:3000 OLD CASTLE LN
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7346
Mailing Address - Country:US
Mailing Address - Phone:347-515-5039
Mailing Address - Fax:
Practice Address - Street 1:101 S PARK AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3627
Practice Address - Country:US
Practice Address - Phone:208-715-7551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health