Provider Demographics
NPI:1871304238
Name:COTTLE, TY ALAN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TY
Middle Name:ALAN
Last Name:COTTLE
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 321
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83431-0321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 RIGBY LAKE DR STE 102
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5230
Practice Address - Country:US
Practice Address - Phone:208-973-9413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-15
Last Update Date:2025-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1471648363LP0808X, 2084P0804X, 2084P0805X, 2084S0012X, 2084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine