Provider Demographics
NPI:1689967135
Name:CANADA, DEIDRE MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:MICHELLE
Last Name:CANADA
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 1:10101 LINN STATION RD STE 600
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3818
Mailing Address - Country:US
Mailing Address - Phone:502-589-8600
Mailing Address - Fax:502-287-0662
Practice Address - Street 1:10101 LINN STATION RD STE 600
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3818
Practice Address - Country:US
Practice Address - Phone:502-589-8600
Practice Address - Fax:502-287-0662
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2534331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical