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General NPI Number Information
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NPI Number | 1619539947
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Entity Type | Individual
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Provider Name | KELLI TILLQUIST PSYD
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Gender | Female
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Dates
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Enumeration Date | 07/08/2019
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Last Update Date | 08/08/2025
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Provider Practice Location Address
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Address Line | 1529 W BELMONT ST
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City | BOISE
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State | ID
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Zip | 83725-2336
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Country | US
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Telephone | 208-426-2987
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 45056
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City | BOISE
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State | ID
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Zip | 83711-5056
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Country | US
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Telephone | 208-859-1906
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY-203634
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 203634
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License Number State | ID
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