Healthcare Provider Details

I. General information

NPI: 1720348097
Provider Name (Legal Business Name): TIFFANY JEAN KRUMM L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. TIFFANY JEAN BILLINGTON

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 S BRIDGE WAY PL
EAGLE ID
83616-6099
US

IV. Provider business mailing address

1032 S BRIDGE WAY PL
EAGLE ID
83616-6099
US

V. Phone/Fax

Practice location:
  • Phone: 208-475-0800
  • Fax: 208-246-0125
Mailing address:
  • Phone: 208-475-0800
  • Fax: 208-246-0125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC-4758
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-4758
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-4758
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberLPC-4758
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: