Basic Information
| Provider Information | |||||||||
| NPI: | 1205199007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVLIN | ||||||||
| FirstName: | RIKKI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2321 E GALA ST | ||||||||
| Address2: | STE 3 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836427692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088885848 | ||||||||
| FaxNumber: | 2088880840 | ||||||||
| Practice Location | |||||||||
| Address1: | 2321 E GALA ST | ||||||||
| Address2: | STE 3 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836427692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088885848 | ||||||||
| FaxNumber: | 2088880840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2012 | ||||||||
| LastUpdateDate: | 12/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW32149 | ID | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 20001411 | 01 | ID | MEDICARE PTAN | OTHER |