Provider Demographics
NPI:1245856095
Name:ZIMMERLY, TINA RAE (LMSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:RAE
Last Name:ZIMMERLY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:RAE
Other - Last Name:MANCUSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:702 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-3121
Mailing Address - Country:US
Mailing Address - Phone:541-889-9167
Mailing Address - Fax:541-889-7873
Practice Address - Street 1:8601 W EMERALD ST STE 130
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8209
Practice Address - Country:US
Practice Address - Phone:208-600-2184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLMSW-40409OtherIDAHO BOARD OF SOCIAL WORK EXAMINERS