Provider Demographics
NPI:1659599850
Name:TYLER T WHITNEY PSYD PC
Entity Type:Organization
Organization Name:TYLER T WHITNEY PSYD PC
Other - Org Name:INTERMOUNTAIN CENTER FOR AUTISM & CHILD DEVELOPMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:T
Authorized Official - Last Name:WHITNEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:208-888-7104
Mailing Address - Street 1:2273 E GALA ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7289
Mailing Address - Country:US
Mailing Address - Phone:208-888-7104
Mailing Address - Fax:208-321-4789
Practice Address - Street 1:2273 E GALA ST
Practice Address - Street 2:SUITE 120
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7289
Practice Address - Country:US
Practice Address - Phone:208-888-7104
Practice Address - Fax:208-321-4789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSE-202327101YM0800X
IDSE202-374101YM0800X
IDPSY202-131103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty