Provider Demographics
NPI:1659522365
Name:FARADAY, DARLA JANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DARLA
Middle Name:JANE
Last Name:FARADAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:DARLA
Other - Middle Name:JANE
Other - Last Name:LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:111 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5919
Mailing Address - Country:US
Mailing Address - Phone:208-523-1130
Mailing Address - Fax:208-529-6501
Practice Address - Street 1:111 E 16TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5919
Practice Address - Country:US
Practice Address - Phone:208-523-1130
Practice Address - Fax:208-529-6501
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202441103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808091400Medicaid