Provider Demographics
NPI:1043620115
Name:MCDONALD, BRADEN CLARK (LMSW)
Entity Type:Individual
Prefix:
First Name:BRADEN
Middle Name:CLARK
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 2ND AVE W
Mailing Address - Street 2:361 2ND AVE WEST
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5804
Mailing Address - Country:US
Mailing Address - Phone:208-308-7533
Mailing Address - Fax:
Practice Address - Street 1:361 2ND AVE WEST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-308-7533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8729371-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker