| NPI | 1912234642 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER STILES LICKEY Owner 208-667-2870 |
| Organization Subpart ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: ID PSY-428) |
| Enumeration Date | 2009-11-18 |
| Last Update Date | 2009-11-18 |