Provider Demographics
NPI:1780202440
Name:SMITH, TARA LYNN HENDRICKSON (LCSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN HENDRICKSON
Last Name:SMITH
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 1:905 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-7913
Mailing Address - Country:US
Mailing Address - Phone:208-412-1207
Mailing Address - Fax:208-321-0221
Practice Address - Street 1:4477 W EMERALD ST STE C100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2058
Practice Address - Country:US
Practice Address - Phone:208-321-0160
Practice Address - Fax:208-321-0221
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID39796104100000X
IDLCSW-437731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker