Provider Demographics
NPI:1518102797
Name:NORTHWEST NEUROBEHAVIORAL HEALTH PLLC
Entity type:Organization
Organization Name:NORTHWEST NEUROBEHAVIORAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:208-672-8699
Mailing Address - Street 1:6003 OVERLAND RD STE 301
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-3077
Mailing Address - Country:US
Mailing Address - Phone:208-672-8699
Mailing Address - Fax:208-672-9308
Practice Address - Street 1:6003 OVERLAND RD STE 301
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-3077
Practice Address - Country:US
Practice Address - Phone:208-672-8699
Practice Address - Fax:208-672-9308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY202444103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1306914643OtherIND NPI