Provider Demographics
NPI:1336829845
Name:DEREIX CALONGE, IDUAR
Entity Type:Individual
Prefix:
First Name:IDUAR
Middle Name:
Last Name:DEREIX CALONGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 LITTLEROCK RD SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7332
Mailing Address - Country:US
Mailing Address - Phone:360-704-7590
Mailing Address - Fax:
Practice Address - Street 1:6334 LITTLEROCK RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7332
Practice Address - Country:US
Practice Address - Phone:360-704-7590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61421303101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health