Provider Demographics
NPI:1124412747
Name:IVIE, TARYN SUZANNE (CADC)
Entity Type:Individual
Prefix:MRS
First Name:TARYN
Middle Name:SUZANNE
Last Name:IVIE
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 N 3300 E
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:ID
Mailing Address - Zip Code:83420-5018
Mailing Address - Country:US
Mailing Address - Phone:208-589-9054
Mailing Address - Fax:208-624-1351
Practice Address - Street 1:1320 N 3300 E
Practice Address - Street 2:
Practice Address - City:ASHTON
Practice Address - State:ID
Practice Address - Zip Code:83420-5018
Practice Address - Country:US
Practice Address - Phone:208-589-9054
Practice Address - Fax:208-624-1351
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10221101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)