Provider Demographics
NPI:1780010090
Name:PSYCHOLOGY CENTER OF IDAHO FALLS
Entity type:Organization
Organization Name:PSYCHOLOGY CENTER OF IDAHO FALLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CLIICAL NEUROPSYCHOLOGIS
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD ABPP-CN
Authorized Official - Phone:208-522-3404
Mailing Address - Street 1:3670 S 25TH E STE 2
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4956
Mailing Address - Country:US
Mailing Address - Phone:208-522-3404
Mailing Address - Fax:208-524-1093
Practice Address - Street 1:3670 S 25TH E STE 2
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4956
Practice Address - Country:US
Practice Address - Phone:208-522-3404
Practice Address - Fax:208-524-1093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID202288103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1684801Medicare UPIN