Healthcare Provider Details

I. General information

NPI: 1164570842
Provider Name (Legal Business Name): DEBORAH K SCUDDER MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W CAMERON AVE
KELLOGG ID
83837-2004
US

IV. Provider business mailing address

601 W CAMERON AVE
KELLOGG ID
83837-2004
US

V. Phone/Fax

Practice location:
  • Phone: 208-784-1283
  • Fax: 208-784-0151
Mailing address:
  • Phone: 208-784-1283
  • Fax: 208-784-0151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW365
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: