Provider Demographics
NPI:1689967135
Name:CANADA, DEIDRE MICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:DEIDRE
Middle Name:MICHELLE
Last Name:CANADA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:WADDY
Mailing Address - State:KY
Mailing Address - Zip Code:40076-0008
Mailing Address - Country:US
Mailing Address - Phone:502-548-5482
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 8
Practice Address - Street 2:
Practice Address - City:WADDY
Practice Address - State:KY
Practice Address - Zip Code:40076-0008
Practice Address - Country:US
Practice Address - Phone:502-548-5482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2534331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical