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NPI Code Detail

MEDICARE: TIARA LITTLEDYKE LCSW

MEDICARE: TIARA LITTLEDYKE LCSW
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
1104100000XSocial Worker9569161-3502UT
21041C0700XClinical Social Worker9569161-3501UT
31041C0700XClinical Social WorkerLCSW-45118ID

General Provider Information

NPI Number : 1588904049
Entity Type Code : Individual
Provider Name (Legal Business Name) : TIARA LITTLEDYKE LCSW
Provider Business Mailing Address
First Line : 190 E BANNOCK ST
Second Line :
City : BOISE
State : ID
Zip : 83712-6241
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 815 N COLLEGE RD
Second Line :
City : TWIN FALLS
State : ID
Zip : 83301-3484
Country : US
Telephone Number : 208-814-9100
Fax Number : 208-814-9903
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/20/2013
Last Update Date : 10/16/2024

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Directions to “ TIARA LITTLEDYKE LCSW” Practice Location

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