Provider Demographics
NPI:1922129840
Name:PSYCHOLOGICAL ASSESSMENT SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL ASSESSMENT SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-236-1600
Mailing Address - Street 1:PO BOX 4986
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4986
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:208-236-6695
Practice Address - Street 1:500 S 11TH AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4835
Practice Address - Country:US
Practice Address - Phone:208-233-0150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101Y00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378795Medicare ID - Type Unspecified