Provider Demographics
NPI:1619514510
Name:DECORY, CEDRIC JOESPH JR (LMSW)
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:JOESPH
Last Name:DECORY
Suffix:JR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4724 W FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1217
Mailing Address - Country:US
Mailing Address - Phone:208-412-0230
Mailing Address - Fax:
Practice Address - Street 1:2273 S VISTA AVE STE 190
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-7341
Practice Address - Country:US
Practice Address - Phone:208-343-2737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-392431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical