Provider Demographics
NPI:1003097437
Name:SANNA, DEDRA CHRISTINE (LCPC)
Entity type:Individual
Prefix:MS
First Name:DEDRA
Middle Name:CHRISTINE
Last Name:SANNA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MRS
Other - First Name:DEDRA
Other - Middle Name:CHRISTINE
Other - Last Name:QUINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:409 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4520
Mailing Address - Country:US
Mailing Address - Phone:208-234-2646
Mailing Address - Fax:208-232-0035
Practice Address - Street 1:409 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4520
Practice Address - Country:US
Practice Address - Phone:208-234-2646
Practice Address - Fax:208-232-0035
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC274101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health