Provider Demographics
NPI:1780625954
Name:CONNOR, TIMOTHY A (PSYD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:A
Last Name:CONNOR
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S WOODRUFF AVE
Mailing Address - Street 2:SUITE J
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4369
Mailing Address - Country:US
Mailing Address - Phone:208-529-5548
Mailing Address - Fax:208-529-5588
Practice Address - Street 1:211 S WOODRUFF AVE
Practice Address - Street 2:SUITE J
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4369
Practice Address - Country:US
Practice Address - Phone:208-529-5548
Practice Address - Fax:208-529-5588
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID202118103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDN6279OtherBLUE CROSS
ID000010155441OtherREGENCE BLUE SHIELD
ID000010155441OtherREGENCE BLUE SHIELD