Basic Information
Provider Information | |||||||||
NPI: | 1669623039 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERDA | ||||||||
FirstName: | DEXTER | ||||||||
MiddleName: | CRUTHAIM | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D., LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 715 HORIZON DR STE 225 | ||||||||
Address2: |   | ||||||||
City: | GRAND JUNCTION | ||||||||
State: | CO | ||||||||
PostalCode: | 815068743 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 515 28 3/4 RD | ||||||||
Address2: |   | ||||||||
City: | GRAND JUNCTION | ||||||||
State: | CO | ||||||||
PostalCode: | 815015016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702634918 | ||||||||
FaxNumber: | 9706837278 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2008 | ||||||||
LastUpdateDate: | 10/14/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW.00992440 | CO | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 992440 | 01 | CO | LISENSED SOCIAL WORKER AND PHD PSYCHOLOGY | OTHER |