Healthcare Provider Details

I. General information

NPI: 1427499193
Provider Name (Legal Business Name): BRENDA HAMMOND LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 EVERGREEN RD
SAGLE ID
83860
US

IV. Provider business mailing address

300 EVERGREEN RD
SAGLE ID
83860
US

V. Phone/Fax

Practice location:
  • Phone: 208-290-7961
  • Fax:
Mailing address:
  • Phone: 208-290-7961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW32905
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number32905
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: