Basic Information
| Provider Information | |||||||||
| NPI: | 1437219227 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHOLOGY SERVICES OF IDAHO, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2365 E GALA ST | ||||||||
| Address2: | SUITE #2 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836424881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082881920 | ||||||||
| FaxNumber: | 2082882844 | ||||||||
| Practice Location | |||||||||
| Address1: | 2365 E GALA ST | ||||||||
| Address2: | SUITE #2 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836424881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082881920 | ||||||||
| FaxNumber: | 2082882844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHAMPION | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2082881920 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 7503219 | 01 | ID | AETNA | OTHER |