Provider Demographics
NPI:1881980357
Name:TIMBERLAKE, DANIEL EDWARD (PHD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:EDWARD
Last Name:TIMBERLAKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 S HORSESHOE PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716
Mailing Address - Country:US
Mailing Address - Phone:208-608-6484
Mailing Address - Fax:
Practice Address - Street 1:1910 UNIVERSITY DR
Practice Address - Street 2:MS 1351
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-1351
Practice Address - Country:US
Practice Address - Phone:208-426-1459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202436103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist