Provider Demographics
NPI:1023464310
Name:TAGUE, GLORIA (LSW)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:TAGUE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19626 PRESCOTT LN
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-8132
Mailing Address - Country:US
Mailing Address - Phone:208-459-0092
Mailing Address - Fax:208-454-7714
Practice Address - Street 1:3402 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6932
Practice Address - Country:US
Practice Address - Phone:208-459-0092
Practice Address - Fax:208-454-7714
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-2339104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker