Healthcare Provider Details

I. General information

NPI: 1952925604
Provider Name (Legal Business Name): TYLAR SWANSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 W SANETTA ST
NAMPA ID
83651-5047
US

IV. Provider business mailing address

305 S ELM ST APT 210
BOISE ID
83712-7815
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-7443
  • Fax:
Mailing address:
  • Phone: 319-931-2358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number39664
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: