Individual
PHARES L BOOK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSY.D,LPC
Contact information
Practice address
815 FILLMORE ST, CALDWELL, ID 83605-4126
(208) 459-6962
(208) 459-4476
Mailing address
815 FILLMORE ST, CALDWELL, ID 83605-4126
(208) 459-6962
(208) 459-4476
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
202193
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
807284400
—
ID
Enumeration date
07/14/2006
Last updated
01/24/2012
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