Provider Demographics
NPI:1588395768
Name:SHADWICK, DARBY
Entity type:Individual
Prefix:
First Name:DARBY
Middle Name:
Last Name:SHADWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26783 DEB LN
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:ID
Mailing Address - Zip Code:83660-7275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26783 DEB LN
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:ID
Practice Address - Zip Code:83660-7275
Practice Address - Country:US
Practice Address - Phone:208-697-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician