Provider Demographics
NPI:1316080179
Name:FOX STEWART, TAMBRA EVE (LCSW)
Entity type:Individual
Prefix:
First Name:TAMBRA
Middle Name:EVE
Last Name:FOX STEWART
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 N TRAIL CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4090
Mailing Address - Country:US
Mailing Address - Phone:208-938-5364
Mailing Address - Fax:
Practice Address - Street 1:1111 S ORCHARD ST
Practice Address - Street 2:SUITE 172
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1966
Practice Address - Country:US
Practice Address - Phone:208-336-9591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW - 293191041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCSW - 29319Medicaid
IDLCSW - 29319Medicare UPIN