Provider Demographics
NPI:1033551015
Name:WILLIS, TANNA SUSAN (LCMT)
Entity Type:Individual
Prefix:
First Name:TANNA
Middle Name:SUSAN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83725-1351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1529 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-0001
Practice Address - Country:US
Practice Address - Phone:208-426-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-732225700000X
ID820290701261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health