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General NPI Number Information
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NPI Number | 1033575394
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Entity Type | Organization
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Legal Business Name | TALLAHASSEE THERAPY ASSOCIATES, LLC
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Dates
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Enumeration Date | 01/01/2016
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Last Update Date | 01/01/2016
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Provider Practice Location Address
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Address Line | 109 W 4TH AVE
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City | TALLAHASSEE
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State | FL
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Zip | 32303-6152
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Country | US
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Telephone | 850-241-5707
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Fax |
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Provider Business Mailing Address
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Address Line | 10678 LAKE IAMONIA DR
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City | TALLAHASSEE
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State | FL
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Zip | 32312-5102
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Country | US
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Telephone | 850-597-5050
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MICHELLE BOUTHILLIER
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Credential | LCSW, CGP
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Telephone | 850-241-5707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | SW11731
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License Number State | FL
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