MEDICARE: DANIEL EDWARD TIMBERLAKE PHD

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	103T00000X	Psychologist	PSY-202436	ID

General Provider Information

NPI Number	:	1881980357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL EDWARD TIMBERLAKE PHD

Provider Business Mailing Address
First Line	:	5840 S HORSESHOE PL
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83716
Country	:	US
Telephone Number	:	208-608-6484
Fax Number	:

Provider Business Practice Location Address
First Line	:	1910 UNIVERSITY DR
Second Line	:	MS 1351
City	:	BOISE
State	:	ID
Zip	:	83725-1351
Country	:	US
Telephone Number	:	208-426-1459
Fax Number	:

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

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	06/23/2011

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