Healthcare Provider Details

I. General information

NPI: 1225569338
Provider Name (Legal Business Name): TABATHA JO BAUMGARTNER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TABATHA JO CARSON

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 6TH ST
RUPERT ID
83350-1621
US

IV. Provider business mailing address

402 6TH ST
RUPERT ID
83350-1619
US

V. Phone/Fax

Practice location:
  • Phone: 208-436-4911
  • Fax: 208-436-1758
Mailing address:
  • Phone: 208-650-7941
  • Fax: 208-436-0735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-36530
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-44878
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: