Provider Demographics
NPI:1477162675
Name:MCFADDAN, DEHRA (LMSW)
Entity Type:Individual
Prefix:
First Name:DEHRA
Middle Name:
Last Name:MCFADDAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E. COEUR D'ALENE AVE
Mailing Address - Street 2:102
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-699-6817
Mailing Address - Fax:208-620-2306
Practice Address - Street 1:211 E. COEUR D'ALENE AVE
Practice Address - Street 2:102
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-699-6817
Practice Address - Fax:208-620-2306
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID39680104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLMSW39680OtherCLINICAL LICENSE