MEDICARE: DIANA TERESA HENDRICKSON LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker		ID

General Provider Information

NPI Number	:	1457281636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA TERESA HENDRICKSON LMSW

Provider Business Mailing Address
First Line	:	5292 W MALAD ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83705-3742
Country	:	US
Telephone Number	:	208-949-3656
Fax Number	:

Provider Business Practice Location Address
First Line	:	1901 N LAKES PL # 150
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5939
Country	:	US
Telephone Number	:	208-890-7165
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2026
Last Update Date	:	05/20/2026

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