1639853286 NPI number — MR. SEBASTIAN DAVID CALDERON LMSW

Table of content: ANGELA L FORSYTH PT (NPI 1467726083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639853286 NPI number — MR. SEBASTIAN DAVID CALDERON LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALDERON
Provider First Name:
SEBASTIAN
Provider Middle Name:
DAVID
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
M

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:
1639853286
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
740 W 176 LN S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAUL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83347-8697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-650-5822
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1360 ALBION AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-1818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-878-7008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2023

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 6471144 , 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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