Healthcare Provider Details

I. General information

NPI: 1588904049
Provider Name (Legal Business Name): TIARA LITTLEDYKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N COLLEGE RD
TWIN FALLS ID
83301-3484
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-9100
  • Fax: 208-814-9903
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9569161-3502
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9569161-3501
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-45118
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: