Healthcare Provider Details

I. General information

NPI: 1033551015
Provider Name (Legal Business Name): TANNA SUSAN WILLIS LCMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 07/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 BELMONT ST
BOISE ID
83725-0001
US

IV. Provider business mailing address

1910 UNIVERSITY DR
BOISE ID
83725-1351
US

V. Phone/Fax

Practice location:
  • Phone: 208-426-1459
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAS-732
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number820290701
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: