Healthcare Provider Details

I. General information

NPI: 1568184786
Provider Name (Legal Business Name): TRINITA ANNYS ROSE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRINITA ANNYS DYE LMSW

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 N. MAIN STREET 2ND FLOOR, UNIT #5
KETCHUM ID
83340
US

IV. Provider business mailing address

PO BOX 426
HAILEY ID
83333-0400
US

V. Phone/Fax

Practice location:
  • Phone: 208-481-4639
  • Fax:
Mailing address:
  • Phone: 208-481-4639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-36738
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: