Healthcare Provider Details

I. General information

NPI: 1033537626
Provider Name (Legal Business Name): DEEMARLA TAVARES LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W SELTICE WAY
COEUR D ALENE ID
83814-8921
US

IV. Provider business mailing address

2201 IRONWOOD PL
COEUR D ALENE ID
83814-2670
US

V. Phone/Fax

Practice location:
  • Phone: 208-620-5250
  • Fax:
Mailing address:
  • Phone: 208-769-4222
  • Fax: 208-667-7557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW-30760
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: