Provider Demographics
NPI:1376766378
Name:COLLIAS, TIMOTHY J (MA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:COLLIAS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1471 SHORELINE DR
Mailing Address - Street 2:SUITE 119
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6879
Mailing Address - Country:US
Mailing Address - Phone:208-345-2630
Mailing Address - Fax:208-345-6504
Practice Address - Street 1:1471 SHORELINE DR
Practice Address - Street 2:SUITE 119
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6879
Practice Address - Country:US
Practice Address - Phone:208-345-2630
Practice Address - Fax:208-345-6504
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-2001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical