Provider Demographics
NPI:1396274932
Name:REARDON, NAVARA (LMSW)
Entity type:Individual
Prefix:
First Name:NAVARA
Middle Name:
Last Name:REARDON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 E HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3238
Mailing Address - Country:US
Mailing Address - Phone:208-660-4675
Mailing Address - Fax:208-666-4122
Practice Address - Street 1:6795 N MINERAL DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8700
Practice Address - Country:US
Practice Address - Phone:208-769-4222
Practice Address - Fax:844-803-7399
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID392791041C0700X
IDLMSW-36784104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2082112Medicaid