Healthcare Provider Details

I. General information

NPI: 1518638071
Provider Name (Legal Business Name): HEATHER MARIE DEUEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 POLK ST STE A
TWIN FALLS ID
83301-3916
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-9100
  • Fax: 208-814-9140
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-40597
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8861558
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: