1629373568 NPI number — DALANA JUSTESEN-BAXTER LSW, CADC

Table of content: DALANA JUSTESEN-BAXTER LSW, CADC (NPI 1629373568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629373568 NPI number — DALANA JUSTESEN-BAXTER LSW, CADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUSTESEN-BAXTER
Provider First Name:
DALANA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSW, CADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629373568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 11TH AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOODING
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83330-5368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-934-8461
Provider Business Mailing Address Fax Number:
208-934-5437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
762 FALLS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-3316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-4200
Provider Business Practice Location Address Fax Number:
208-734-1404
Provider Enumeration Date:
01/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  11540036 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: LSW-30781 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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