Basic Information
| Provider Information | |||||||||
| NPI: | 1568766566 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST NEUROBEHAVIORAL HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2950 E MAGIC VIEW DR STE 140 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083239130 | ||||||||
| FaxNumber: | 2083239070 | ||||||||
| Practice Location | |||||||||
| Address1: | 2950 E MAGIC VIEW DR STE 140 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083239130 | ||||||||
| FaxNumber: | 2083239070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2011 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | JEREMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2083239130 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PSY-202444 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.