Provider Demographics
NPI:1346574464
Name:NIELSEN, TANNER MITCHELL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TANNER
Middle Name:MITCHELL
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S WOODRUFF AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6371
Mailing Address - Country:US
Mailing Address - Phone:208-419-3002
Mailing Address - Fax:208-656-5652
Practice Address - Street 1:2001 S WOODRUFF AVE STE 9
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6371
Practice Address - Country:US
Practice Address - Phone:208-419-3002
Practice Address - Fax:208-656-5652
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-203073103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical