Provider Demographics
NPI:1265862783
Name:REARDON, NAOMI
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:REARDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 N 4TH AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6390
Mailing Address - Country:US
Mailing Address - Phone:208-233-7832
Mailing Address - Fax:208-233-7835
Practice Address - Street 1:353 N 4TH AVE
Practice Address - Street 2:STE 110
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6390
Practice Address - Country:US
Practice Address - Phone:208-233-7832
Practice Address - Fax:208-233-7835
Is Sole Proprietor?:No
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health