Provider Demographics
NPI:1538492897
Name:CHANNER, TYLENE K (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TYLENE
Middle Name:K
Last Name:CHANNER
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 1:2965 E TARPON DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9009
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:208-287-9426
Practice Address - Street 1:5700 E FRANKLIN RD
Practice Address - Street 2:SUITE 220E
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-8497
Practice Address - Country:US
Practice Address - Phone:208-936-1097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-294271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical