Provider Demographics
NPI:1508100876
Name:BIG LAKE PSYCHOLOGICAL SERVICES, PC
Entity Type:Organization
Organization Name:BIG LAKE PSYCHOLOGICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:REHIL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:208-550-3165
Mailing Address - Street 1:1104 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2605
Mailing Address - Country:US
Mailing Address - Phone:208-550-3165
Mailing Address - Fax:
Practice Address - Street 1:1809 E SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5873
Practice Address - Country:US
Practice Address - Phone:208-665-9611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202671103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty