Provider Demographics
NPI:1295881480
Name:BOLIOU, NEAL (PHYD)
Entity type:Individual
Prefix:
First Name:NEAL
Middle Name:
Last Name:BOLIOU
Suffix:
Gender:M
Credentials:PHYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 S FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1306
Mailing Address - Country:US
Mailing Address - Phone:208-375-7777
Mailing Address - Fax:208-375-7598
Practice Address - Street 1:1327 S FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1306
Practice Address - Country:US
Practice Address - Phone:208-375-7777
Practice Address - Fax:208-445-5899
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-247103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010016161OtherREGENCE BLUE SHIELD OF ID
IDN9998OtherBLUE CROSS OF IDAHO
ID000010016161OtherREGENCE BLUE SHIELD OF ID