Provider Demographics
NPI:1174007884
Name:DANAHAR, DEIRDRE M (LICSW)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:M
Last Name:DANAHAR
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 BROOK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5932
Mailing Address - Country:US
Mailing Address - Phone:601-362-8288
Mailing Address - Fax:
Practice Address - Street 1:4410 BROOK DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5932
Practice Address - Country:US
Practice Address - Phone:601-362-8288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC71111041C0700X
MA1106071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110607-SW-LICSWOtherDIVISION OF PROFESSIONAL LICENSURE, BOARD OF REGISTRATION OF SOCIAL WORKERS