Healthcare Provider Details

I. General information

NPI: 1336167261
Provider Name (Legal Business Name): RYAN C TORNGREN MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2241 OVERLAND AVE STE 3
BURLEY ID
83318-2929
US

IV. Provider business mailing address

2241 OVERLAND AVE STE 3
BURLEY ID
83318-2929
US

V. Phone/Fax

Practice location:
  • Phone: 208-677-5332
  • Fax: 208-677-4002
Mailing address:
  • Phone: 208-677-5332
  • Fax: 208-677-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-27457
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-29633
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: