Provider Demographics
NPI:1386767499
Name:JOHN, TIMMIE LYN (LMSW)
Entity type:Individual
Prefix:MRS
First Name:TIMMIE
Middle Name:LYN
Last Name:JOHN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 E 1270 N
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-4902
Mailing Address - Country:US
Mailing Address - Phone:208-206-2864
Mailing Address - Fax:
Practice Address - Street 1:1600 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4300
Practice Address - Country:US
Practice Address - Phone:208-529-5279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-27752104100000X
IDLCSW-325541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker