Provider Demographics
NPI:1508290115
Name:WILKERSON, TINA (LCSW)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:WERMERSKIRCHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:310 W UNION ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4450
Mailing Address - Country:US
Mailing Address - Phone:208-830-8655
Mailing Address - Fax:
Practice Address - Street 1:310 W UNION ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4450
Practice Address - Country:US
Practice Address - Phone:208-830-8655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-280141041C0700X
ID280141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical