Provider Demographics
NPI:1033575394
Name:TALLAHASSEE THERAPY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:TALLAHASSEE THERAPY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTHILLIER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CGP
Authorized Official - Phone:850-241-5707
Mailing Address - Street 1:10678 LAKE IAMONIA DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-5102
Mailing Address - Country:US
Mailing Address - Phone:850-597-5050
Mailing Address - Fax:
Practice Address - Street 1:109 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-6152
Practice Address - Country:US
Practice Address - Phone:850-241-5707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-01
Last Update Date:2016-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW11731251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health