Provider Demographics
NPI:1275014045
Name:DEGRAW, RICHARD HAROLD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:HAROLD
Last Name:DEGRAW
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 1:60 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1825
Mailing Address - Country:US
Mailing Address - Phone:208-359-3300
Mailing Address - Fax:208-359-3345
Practice Address - Street 1:60 W MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1825
Practice Address - Country:US
Practice Address - Phone:208-359-3300
Practice Address - Fax:208-359-3345
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6097101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health