Provider Demographics
NPI:1669623039
Name:HERDA, DEXTER CRUTHAIM (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:DEXTER
Middle Name:CRUTHAIM
Last Name:HERDA
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:715 HORIZON DR STE 225
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 28 3/4 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-5016
Practice Address - Country:US
Practice Address - Phone:970-263-4918
Practice Address - Fax:970-683-7278
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.009924401041C0700X
KS81851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO992440OtherLISENSED SOCIAL WORKER AND PHD PSYCHOLOGY
CO992440OtherLISENSED SOCIAL WORKER AND PHD PSYCHOLOGY