Provider Demographics
NPI:1790241404
Name:BOISE BRAIN HEALTH
Entity Type:Organization
Organization Name:BOISE BRAIN HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARION
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-917-1692
Mailing Address - Street 1:4696 W OVERLAND RD STE 228
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2864
Mailing Address - Country:US
Mailing Address - Phone:208-917-1692
Mailing Address - Fax:208-914-7643
Practice Address - Street 1:4696 W OVERLAND RD STE 228
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2864
Practice Address - Country:US
Practice Address - Phone:208-917-1692
Practice Address - Fax:208-914-7643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty