Provider Demographics
NPI:1689918401
Name:IDROGO, ELIZABETH ANN (BS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:IDROGO
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 INDIO ST
Mailing Address - Street 2:
Mailing Address - City:TULELAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96134-9278
Mailing Address - Country:US
Mailing Address - Phone:530-640-0925
Mailing Address - Fax:
Practice Address - Street 1:2210 N ELDORADO AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6418
Practice Address - Country:US
Practice Address - Phone:541-883-1030
Practice Address - Fax:541-884-2338
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR223354Medicaid