Basic Information
| Provider Information | |||||||||
| NPI: | 1871672840 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHOLOGICAL SERVICE ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3480 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834033480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085252662 | ||||||||
| Practice Location | |||||||||
| Address1: | 2235 E 25TH ST | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085252662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 06/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | HARPER | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2085520490 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | LMFT-2661 | ID | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103TC0700X | PSY-386 | ID | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 806472900 | 05 | ID | MEDICAID |