Healthcare Provider Details

I. General information

NPI: 1558896506
Provider Name (Legal Business Name): NICHOLAS TOCK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 E PARK BLVD
BOISE ID
83712-7722
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-5970
  • Fax: 208-381-5971
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09928268
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801117495
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-40831
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: