Provider Demographics
NPI:1861256422
Name:DAFFERN, ELIZABETH ASHLEA (MS)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ASHLEA
Last Name:DAFFERN
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 1:685 BROOKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-3305
Mailing Address - Country:US
Mailing Address - Phone:208-358-5308
Mailing Address - Fax:
Practice Address - Street 1:1993 E 8TH N
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2326
Practice Address - Country:US
Practice Address - Phone:208-587-7626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-10230101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health