Provider Demographics
NPI:1861837601
Name:DESANTIS, TIMOTHY STEPHEN (LCPC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:STEPHEN
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 CHELSEY CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-4634
Mailing Address - Country:US
Mailing Address - Phone:208-672-8764
Mailing Address - Fax:
Practice Address - Street 1:8620 W EMERALD ST
Practice Address - Street 2:SUITE 150
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4824
Practice Address - Country:US
Practice Address - Phone:208-672-2900
Practice Address - Fax:208-672-2919
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4671101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)