Provider Demographics
NPI:1356702336
Name:HIBDON, DEA (LCPC)
Entity type:Individual
Prefix:
First Name:DEA
Middle Name:
Last Name:HIBDON
Suffix:
Gender:F
Credentials:LCPC
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 B
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-0182
Mailing Address - Country:US
Mailing Address - Phone:208-799-4440
Mailing Address - Fax:208-799-5171
Practice Address - Street 1:PO BOX B
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-0182
Practice Address - Country:US
Practice Address - Phone:208-799-4440
Practice Address - Fax:208-799-5171
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-5197101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCPC-5197OtherSTATE OF IDAHO