Provider Demographics
NPI:1891014320
Name:BAILLY-RENNER, TIFFANY (LMSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:BAILLY-RENNER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:BAILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:4736 E DEER RD
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:ID
Mailing Address - Zip Code:83833-7894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2660
Practice Address - Country:US
Practice Address - Phone:208-664-9729
Practice Address - Fax:208-263-7515
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID30167251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health