Healthcare Provider Details

I. General information

NPI: 1235070509
Provider Name (Legal Business Name): DEIDRE COLVIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 ADDISON AVE E
TWIN FALLS ID
83301-6767
US

IV. Provider business mailing address

3147 E CHASEWOOD DR
AMMON ID
83406-4792
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-1000
  • Fax:
Mailing address:
  • Phone: 208-716-4792
  • Fax: 208-716-4792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8921513
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: