Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor | LCPC274 | ID |
NPI | 1003097437 |
---|---|
Provider Name | Ms. Dedra Christine Sanna |
First Address | Pocatello, ID 83201-4520 |
Second Address | Pocatello, ID 83201-4520 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2007 |
Last Update Date | 26/03/2015 |