Individual
MRS. TYLER ROWBERRY MOULTON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
BSBI
Contact information
Practice address
420 CARDINAL DR, SHELLEY, ID 83274-4925
(208) 360-4210
Mailing address
420 CARDINAL DR, SHELLEY, ID 83274-4925
(208) 360-4210
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6169
—
ID
Enumeration date
06/01/2020
Last updated
06/01/2020
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