| Full Name | |
|---|---|
| Speciality | Social Worker |
| Location | 1305 3rd St S, Nampa, Idaho |
| Authorized Official Name and Position | Tylene Channer (OWNER/PRESIDENT) |
| Authorized Official Contact | 2089361097 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1305 3rd St. Nampa ID 83651 Ph: (208) 936-1097 | 1305 3rd St S Nampa ID 83651 Ph: (208) 936-1097 |
| NPI Number | 1043515133 |
|---|---|
| Provider Enumeration Date | 01/20/2011 |
| Last Update Date | 10/06/2017 |
| Medicare PECOS PAC ID | 5890976583 |
|---|---|
| Medicare Enrollment ID | O20110301000685 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1043515133 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | LCSW-29427 (Idaho) | Primary |
| Provider Name | Tylene Channer |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1538492897 PECOS PAC ID: 9234310939 Enrollment ID: I20110301000774 |
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