Healthcare Provider Details

I. General information

NPI: 1275428302
Provider Name (Legal Business Name): TYLER ANDERSON CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 N 400 E STE 104
LOGAN UT
84341-7595
US

IV. Provider business mailing address

500 S 11TH AVE STE 400
POCATELLO ID
83201-4880
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-7862
  • Fax:
Mailing address:
  • Phone: 208-232-7862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number14225907-3502
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: