Provider Demographics
NPI:1760111082
Name:EZZELL-PEBWORTH, DARA J (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:DARA
Middle Name:J
Last Name:EZZELL-PEBWORTH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:DARA
Other - Middle Name:J
Other - Last Name:EZZELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3307 S MILAN AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8158
Mailing Address - Country:US
Mailing Address - Phone:208-389-8338
Mailing Address - Fax:
Practice Address - Street 1:4477 W EMERALD ST STE C100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2058
Practice Address - Country:US
Practice Address - Phone:208-321-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID42343104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker