Provider Demographics
NPI:1245422625
Name:EVERSON, TAMMY L (LCSW)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:EVERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 627
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-0627
Mailing Address - Country:US
Mailing Address - Phone:208-983-0235
Mailing Address - Fax:208-983-0245
Practice Address - Street 1:304 N STATE ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1769
Practice Address - Country:US
Practice Address - Phone:208-983-0235
Practice Address - Fax:208-983-0245
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2023-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-27670101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010150395OtherREGENCE BLUE SHIELD OF IDAHO
L6025OtherBLUE CROSS OF IDAHO
L6025OtherBLUE CROSS OF IDAHO