Provider Demographics
NPI:1891742540
Name:DEIDRICK, KATHLEEN MCCANN (PHD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MCCANN
Last Name:DEIDRICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:KEELY
Other - Last Name:MCCANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:STE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6267
Practice Address - Country:US
Practice Address - Phone:208-381-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003023860103TC0700X
IDPSY202777103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO740169OtherHEALTHLINK
MO205814OtherBLUE SHIELD/BLUE CHOICE
MO491287009Medicaid
MO491287009Medicaid