Provider Demographics
NPI:1568766566
Name:NORTHWEST NEUROBEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:NORTHWEST NEUROBEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-323-9130
Mailing Address - Street 1:2950 E MAGIC VIEW DR STE 140
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9273
Mailing Address - Country:US
Mailing Address - Phone:208-323-9130
Mailing Address - Fax:208-323-9070
Practice Address - Street 1:2950 E MAGIC VIEW DR STE 140
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9273
Practice Address - Country:US
Practice Address - Phone:208-323-9130
Practice Address - Fax:208-323-9070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202444103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty