Provider Demographics
NPI:1407221690
Name:MARTINDALE, TINA MICHELE (LCSW)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MICHELE
Last Name:MARTINDALE
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 1:11407 W REUTZEL DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-4404
Mailing Address - Country:US
Mailing Address - Phone:208-866-7059
Mailing Address - Fax:208-375-9232
Practice Address - Street 1:11407 W REUTZEL DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-4404
Practice Address - Country:US
Practice Address - Phone:208-866-7059
Practice Address - Fax:208-375-9232
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-35315104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker