1760111082 NPI number — MRS. DARA J. EZZELL-PEBWORTH LMSW

Table of content: MRS. DARA J. EZZELL-PEBWORTH LMSW (NPI 1760111082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760111082 NPI number — MRS. DARA J. EZZELL-PEBWORTH LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EZZELL-PEBWORTH
Provider First Name:
DARA
Provider Middle Name:
J.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EZZELL
Provider Other First Name:
DARA
Provider Other Middle Name:
J.
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760111082
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1871 SPANISH FORK WAY APT N204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-5650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-389-8338
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28371 EL PASO RD BLDG A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83607-7521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-972-5514
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2022

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: 104100000X , with the licence number:  42343 , 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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