Basic Information
| Provider Information | |||||||||
| NPI: | 1396274932 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REARDON | ||||||||
| FirstName: | NAVARA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 E HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838143238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086604675 | ||||||||
| FaxNumber: | 2086664122 | ||||||||
| Practice Location | |||||||||
| Address1: | 6795 N MINERAL DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838158700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087694222 | ||||||||
| FaxNumber: | 8448037399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2017 | ||||||||
| LastUpdateDate: | 02/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 39279 | ID | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | LMSW-36784 | ID | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 2082112 | 05 | WA | MEDICAID |