State of Idaho

NPI #1053615260 in Blackfoot, Idaho

Provider Information

NPI Number: 1053615260
Entity Type: Organization
Organization Name: State of Idaho
Subpart: Yes (part of a larger organization)
Parent Organization: STATE HOSPITAL SOUTH
Primary Specialty: Psychologist
Enumeration Date: Jan 3, 2011
Last Updated: Jan 3, 2011

Practice Location

Address: 700 E ALICE ST
City: Blackfoot
State: Idaho
ZIP Code: 83221-4925
Phone: (208) 785-8506

Authorized Official

Name: LORNA B COLVIN
Title: PATIENT ACCOUNT SPECIALIST
Phone: (208) 785-8506

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Psychologist	103T00000X	Primary

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DR. Beth Waddel, PH.D.	Psychologist	Moscow	AI Deep Dive
MRS. Delia Medlin, PH.D.	Psychologist	Lewiston	AI Deep Dive
DR. Kevin Richard Kracke, PH.D.	Psychologist	Lewiston	AI Deep Dive
James A Tyson, PHD	Psychologist	Twin Falls	AI Deep Dive

Organizations

Provider Name	Specialty	City
State of Idaho Department of Health and Welfare Part of State of Idaho Department of Health and Wel	Psychologist	Blackfoot	AI Deep Dive

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