Provider Demographics
NPI:1255631180
Name:TIPPERY, TERRY ALAN (LCSW)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:ALAN
Last Name:TIPPERY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 BANK DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2565
Mailing Address - Country:US
Mailing Address - Phone:208-342-3612
Mailing Address - Fax:208-342-0327
Practice Address - Street 1:2424 BANK DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2565
Practice Address - Country:US
Practice Address - Phone:208-342-3612
Practice Address - Fax:208-342-0327
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-8501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical