Provider Demographics
NPI:1528630357
Name:SELF, DESIREE ANN (MS)
Entity type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:ANN
Last Name:SELF
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 S SILVERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6165
Mailing Address - Country:US
Mailing Address - Phone:440-228-7161
Mailing Address - Fax:
Practice Address - Street 1:244 S SILVERWOOD WAY
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6165
Practice Address - Country:US
Practice Address - Phone:440-228-7161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician