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General NPI Number Information
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NPI Number | 1124397476
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Entity Type | Individual
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Provider Name | DAN TADLOCK LCSW
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Gender | Male
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Dates
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Enumeration Date | 12/15/2011
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Last Update Date | 11/07/2025
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Provider Practice Location Address
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Address Line | 4750 N FIVE MILE RD
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City | BOISE
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State | ID
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Zip | 83713-2715
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Country | US
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Telephone | 888-949-4864
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Fax |
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Provider Business Mailing Address
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Address Line | 3737 W 4100 S
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City | WEST VALLEY CITY
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State | UT
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Zip | 84120-5543
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-29379
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License Number State | ID
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