Healthcare Provider Details

I. General information

NPI: 1780105767
Provider Name (Legal Business Name): EVAN TULLIS ANDERSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S 23RD ST
BOISE ID
83702-9100
US

IV. Provider business mailing address

PO BOX 9
NAMPA ID
83653-0009
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-3512
  • Fax: 208-466-5359
Mailing address:
  • Phone: 208-467-4431
  • Fax: 208-467-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-42535
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34856
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: