Provider Demographics
NPI:1255672614
Name:SEIFERD, IDA AMANDA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:AMANDA
Last Name:SEIFERD
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 ROYAL GORGE BLVD
Mailing Address - Street 2:STE 226
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-6709
Mailing Address - Country:US
Mailing Address - Phone:303-801-8366
Mailing Address - Fax:
Practice Address - Street 1:831 ROYAL GORGE BLVD
Practice Address - Street 2:STE 226
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-6709
Practice Address - Country:US
Practice Address - Phone:303-801-8366
Practice Address - Fax:719-452-3703
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1041C0700X
COCSW.099238371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26-2712955Medicaid