=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598232209
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONYA HOLLIST LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2018
-----------------------------------------------------
Last Update Date | 01/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1223 S RAILROAD AVE
-----------------------------------------------------
City | SUGAR CITY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83448-5072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-359-0519
-----------------------------------------------------
Fax | 208-233-2178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1223 S RAILROAD AVE
-----------------------------------------------------
City | SUGAR CITY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83448-5072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-359-0519
-----------------------------------------------------
Fax | 208-233-2178
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LMSW35094
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW-38181
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------