Provider Demographics
NPI:1629944566
Name:KINDRED MENTAL HEALTH
Entity type:Organization
Organization Name:KINDRED MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOFANOFF
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:208-651-2952
Mailing Address - Street 1:1620 NORTHWEST BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2488
Mailing Address - Country:US
Mailing Address - Phone:208-651-2952
Mailing Address - Fax:
Practice Address - Street 1:1620 NORTHWEST BLVD STE 201
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2488
Practice Address - Country:US
Practice Address - Phone:208-651-2952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)