Kathleen McCann Deidrick, PHD
Individual provider Active NPI Clinical Psychologist · Boise, ID
NPI 1891742540 · NPPES record last updated Feb 21, 2014
Key facts
- NPI
- 1891742540
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Clinical Psychologist 103TC0700X
- License
- PSY202777 (ID)
- Practice address
- 100 E Idaho St
Ste 200
Boise, ID 83712-6267 - Phone
- (208) 381-5000
- NPI assigned
- May 28, 2006
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ID
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20191016000603 | ID | Practitioner - Clinical Psychologist | 4486664737 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY202777 | ID | MD | Clinical Psychologist |
| 2003023860 | MO | MD | Clinical Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| St Lukes Clinic-Treasure Valley LLC | Current |
Accepting new patients |
Locations
190 E Bannock St
Boise, ID 83712
Phone (208) 381-2378
100 E Idaho St
Ste 200
Boise, ID 83712
Phone (208) 381-7312
610 W Hays St
Boise, ID 83702
Phone (208) 345-3530
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 2003023860 | MO | |
| Clinical Psychologist | 103TC0700X | PSY202777 | ID | Yes |
Addresses
Primary practice location
100 E Idaho St
Ste 200
Boise, ID 83712-6267
Mailing address
190 E Bannock St
Boise, ID 83712-6241
Phone (208) 381-2222
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 740169 | Other | MO | HEALTHLINK |
| 205814 | Other | MO | BLUE SHIELD/BLUE CHOICE |
| 491287009 | Medicaid | MO |
Other names
- Kathleen Keely McCann
Other providers in Boise, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 21, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.