Provider Demographics
NPI:1497347694
Name:LODER, KRISTINA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:LODER
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 1:688 POLE LINE RD # 26
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3034
Mailing Address - Country:US
Mailing Address - Phone:208-969-1112
Mailing Address - Fax:208-696-0445
Practice Address - Street 1:139 RIVER VISTA PL STE 201
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3060
Practice Address - Country:US
Practice Address - Phone:208-969-1112
Practice Address - Fax:208-696-0445
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-39984104100000X
IDLCSW-438491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker