| NPI | 1114321163 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JASON SOUTHWICK Manager 208-895-9852 |
| Organization Subpart ? | No |
| Primary Taxonomy | 103G00000X Clinical Neuropsychologist (Licence: ID PSY-202728) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: ID PSY-202728) |
| Enumeration Date | 2014-10-20 |
| Last Update Date | 2024-05-18 |