MEDICARE: MRS. ELIZABETH ASHLEA DAFFERN MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC-10230	ID

General Provider Information

NPI Number	:	1861256422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELIZABETH ASHLEA DAFFERN MS

Provider Business Mailing Address
First Line	:	685 BROOKSIDE CT
Second Line	:
City	:	MOUNTAIN HOME
State	:	ID
Zip	:	83647-3305
Country	:	US
Telephone Number	:	208-358-5308
Fax Number	:

Provider Business Practice Location Address
First Line	:	1993 E 8TH N
Second Line	:
City	:	MOUNTAIN HOME
State	:	ID
Zip	:	83647-2326
Country	:	US
Telephone Number	:	208-587-7626
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2024
Last Update Date	:	02/13/2024

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