Provider Demographics
NPI:1487189163
Name:DANIELS, TYSON (LCSW)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:DANIELS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N 200 W
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-1239
Mailing Address - Country:US
Mailing Address - Phone:208-766-2231
Mailing Address - Fax:208-766-4819
Practice Address - Street 1:150 N 200 W
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-1239
Practice Address - Country:US
Practice Address - Phone:208-766-2231
Practice Address - Fax:208-766-4819
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-366181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical