Provider Demographics
NPI:1437307378
Name:RYAN, TARA J (LCSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:J
Last Name:RYAN
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 1:4696 W OVERLAND RD
Mailing Address - Street 2:SUITE 252
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2845
Mailing Address - Country:US
Mailing Address - Phone:208-345-9300
Mailing Address - Fax:
Practice Address - Street 1:4696 W OVERLAND RD
Practice Address - Street 2:SUITE 252
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2845
Practice Address - Country:US
Practice Address - Phone:208-345-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2015-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker