Basic Information
| Provider Information | |||||||||
| NPI: | 1407221690 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINDALE | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MICHELE | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2965 E TARPON DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 E FRANKLIN RD | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083430441 | ||||||||
| FaxNumber: | 2083434993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2015 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LMSW-35315 | ID | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.