Provider Demographics
NPI:1386919124
Name:SALADA, DOUGLAS PHILLIP (LCSW)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:PHILLIP
Last Name:SALADA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 N MOORE ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3254
Mailing Address - Country:US
Mailing Address - Phone:208-882-3504
Mailing Address - Fax:
Practice Address - Street 1:317 W 6TH ST STE 208
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2387
Practice Address - Country:US
Practice Address - Phone:208-882-3504
Practice Address - Fax:877-935-2107
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-248291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical