Provider Demographics
NPI:1316020779
Name:NIEDERKRUGER, THERESA LEA (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LEA
Last Name:NIEDERKRUGER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3919 HOOVER ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1433
Mailing Address - Country:US
Mailing Address - Phone:208-371-2040
Mailing Address - Fax:
Practice Address - Street 1:3919 HOOVER ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1433
Practice Address - Country:US
Practice Address - Phone:208-371-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-8571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807382800Medicaid
ID830415084 83651 A001OtherTRICARE PROVIDER NUMBER
ID806552901Medicaid
ID807382800Medicaid