MEDICARE: DR. TANNER MITCHELL NIELSEN PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY-203073	ID

General Provider Information

NPI Number	:	1346574464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TANNER MITCHELL NIELSEN PSYD

Provider Business Mailing Address
First Line	:	2001 S WOODRUFF AVE STE 9
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6371
Country	:	US
Telephone Number	:	208-419-3002
Fax Number	:	208-656-5652

Provider Business Practice Location Address
First Line	:	2001 S WOODRUFF AVE STE 9
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6371
Country	:	US
Telephone Number	:	208-419-3002
Fax Number	:	208-656-5652

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2009
Last Update Date	:	11/29/2022

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