Provider Demographics
NPI:1861883266
Name:DANIELSON, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:DANIELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4636 S DENISON AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9201
Mailing Address - Country:US
Mailing Address - Phone:208-305-5261
Mailing Address - Fax:
Practice Address - Street 1:8620 W EMERALD ST STE 150
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4839
Practice Address - Country:US
Practice Address - Phone:208-305-5261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-07
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID339421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical