Provider Demographics
NPI:1881183499
Name:DEVRIES, TODD (MSW)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:DEVRIES
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2726
Mailing Address - Country:US
Mailing Address - Phone:208-847-5996
Mailing Address - Fax:
Practice Address - Street 1:211 S WOODRUFF AVE STE A
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4369
Practice Address - Country:US
Practice Address - Phone:208-524-4818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-37330104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker