Provider Demographics
NPI:1124305347
Name:ALDRICH, CLINTON W (CADC)
Entity type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:W
Last Name:ALDRICH
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 HOMER DR
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-5078
Mailing Address - Country:US
Mailing Address - Phone:208-245-5427
Mailing Address - Fax:209-245-5425
Practice Address - Street 1:89 HOMER DR
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-5078
Practice Address - Country:US
Practice Address - Phone:208-245-5427
Practice Address - Fax:209-245-5425
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10045101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)