Healthcare Provider Details

I. General information

NPI: 1386266708
Provider Name (Legal Business Name): TYLER RICHARDSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 MAIN ST S
KIMBERLY ID
83341-2052
US

IV. Provider business mailing address

311 MAIN ST S
KIMBERLY ID
83341-2052
US

V. Phone/Fax

Practice location:
  • Phone: 208-423-4170
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8911064
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-42391
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: