Provider Demographics
NPI:1922606383
Name:UMPHENOUR, ADETTA D (LMSW)
Entity Type:Individual
Prefix:
First Name:ADETTA
Middle Name:D
Last Name:UMPHENOUR
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6615 COMANCHE STREET
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805
Mailing Address - Country:US
Mailing Address - Phone:208-267-1718
Mailing Address - Fax:208-267-9197
Practice Address - Street 1:6615 COMANCHE STREET
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805
Practice Address - Country:US
Practice Address - Phone:208-267-1718
Practice Address - Fax:208-267-9197
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-39945104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker