Provider Demographics
NPI:1053348441
Name:WARD, CLAY HEROLD (PHD CLINICAL PSYCH)
Entity type:Individual
Prefix:DR
First Name:CLAY
Middle Name:HEROLD
Last Name:WARD
Suffix:
Gender:M
Credentials:PHD CLINICAL PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 465
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634
Mailing Address - Country:US
Mailing Address - Phone:208-631-5063
Mailing Address - Fax:208-887-0950
Practice Address - Street 1:3061 S MERIDIAN RD
Practice Address - Street 2:SUITE 150
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7962
Practice Address - Country:US
Practice Address - Phone:208-631-5063
Practice Address - Fax:208-887-0950
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY239103G00000X, 103T00000X
IDPSY-239103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00001001591OtherREGENCE BLUE SHIELD
1598959322OtherGROUP NPI
IDN2399OtherBLUE CROSS
1680261Medicare PIN