Provider Demographics
NPI:1043751431
Name:DEINES, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:DEINES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11960 W BOWMONT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-6601
Mailing Address - Country:US
Mailing Address - Phone:208-272-0016
Mailing Address - Fax:
Practice Address - Street 1:11960 W BOWMONT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-6601
Practice Address - Country:US
Practice Address - Phone:208-272-0016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID311ZA0620XMedicaid