Provider Demographics
NPI:1023497013
Name:PSYCHOLOGICAL ASSESSMENT SPECIALISTS
Entity type:Organization
Organization Name:PSYCHOLOGICAL ASSESSMENT SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-233-0150
Mailing Address - Street 1:1246 YELLOWSTONE AVE STE C5
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4373
Mailing Address - Country:US
Mailing Address - Phone:208-233-0150
Mailing Address - Fax:208-233-0159
Practice Address - Street 1:1246 YELLOWSTONE AVE STE C5
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4373
Practice Address - Country:US
Practice Address - Phone:208-233-0150
Practice Address - Fax:208-233-0159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSERVICE EXTENDER101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807126900Medicaid