Healthcare Provider Details

I. General information

NPI: 1710739750
Provider Name (Legal Business Name): TYLER DAWN MOULTON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2024
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 11TH AVE E
GOODING ID
83330-5368
US

IV. Provider business mailing address

605 11TH AVE E
GOODING ID
83330-5368
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-8461
  • Fax:
Mailing address:
  • Phone: 208-934-8461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-44450
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: