Provider Demographics
NPI:1871642769
Name:KIPP, DARREL W (MS ACADC)
Entity Type:Individual
Prefix:MR
First Name:DARREL
Middle Name:W
Last Name:KIPP
Suffix:
Gender:M
Credentials:MS ACADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 7TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-746-3889
Mailing Address - Fax:
Practice Address - Street 1:111 BEVER GRADE ROAD
Practice Address - Street 2:NIMIIPOO HEALTH
Practice Address - City:LAPWAI
Practice Address - State:ID
Practice Address - Zip Code:83540
Practice Address - Country:US
Practice Address - Phone:208-843-2391
Practice Address - Fax:208-843-7394
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID83ACADC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)