Basic Information
| Provider Information | |||||||||
| NPI: | 1346441052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.C.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1818 S 10TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836054880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084594412 | ||||||||
| FaxNumber: | 2084597296 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 S 10TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836054880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084594412 | ||||||||
| FaxNumber: | 2084597296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | LCSW-968 | ID | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | L5944 | 01 | ID | BLUE CROSS | OTHER | 000010017051 | 01 | ID | BLUE SHIELD | OTHER |