Provider Demographics
NPI:1043203789
Name:STREET, DEBRA (MSW)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:DEB
Other - Middle Name:
Other - Last Name:STREET
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:0309 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2163
Mailing Address - Country:US
Mailing Address - Phone:208-746-0137
Mailing Address - Fax:208-798-8685
Practice Address - Street 1:0309 2ND ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2163
Practice Address - Country:US
Practice Address - Phone:208-746-0137
Practice Address - Fax:208-798-8685
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-520104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010015964OtherBLUESHIELD OF IDAHO
IDX0367OtherBLUE CROSS OF IDAHO
ID1690991Medicare PIN