Provider Demographics
NPI:1871672840
Name:PSYCHOLOGICAL SERVICE ASSOCIATES
Entity Type:Organization
Organization Name:PSYCHOLOGICAL SERVICE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:K
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-552-0490
Mailing Address - Street 1:PO BOX 3480
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3480
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-525-2662
Practice Address - Street 1:2235 E 25TH ST
Practice Address - Street 2:SUITE 290
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7519
Practice Address - Country:US
Practice Address - Phone:208-525-2090
Practice Address - Fax:208-525-2662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-386103TC0700X
IDLMFT-2661106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806472900Medicaid