Provider Demographics
NPI:1487046785
Name:MCDONALD, COLLEEN M
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:MCDONALD
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:3950 17TH ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-1300
Practice Address - Country:US
Practice Address - Phone:541-523-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL34871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical