Healthcare Provider Details

I. General information

NPI: 1053150458
Provider Name (Legal Business Name): TYLER COOK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 E 50 S STE 2
MALAD CITY ID
83252-1368
US

IV. Provider business mailing address

175 N 100 W
MALAD CITY ID
83252-1236
US

V. Phone/Fax

Practice location:
  • Phone: 208-609-3010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-9421020
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: