Provider Demographics
NPI:1972157642
Name:RADFORD, JOAN
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:RADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3858
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3858
Mailing Address - Country:US
Mailing Address - Phone:208-529-1660
Mailing Address - Fax:
Practice Address - Street 1:3522 BRIAR CREEK LN
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4728
Practice Address - Country:US
Practice Address - Phone:208-529-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-37919104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker