Provider Demographics
NPI:1780105767
Name:ANDERSON, EVAN TULLIS (LMSW)
Entity type:Individual
Prefix:MR
First Name:EVAN
Middle Name:TULLIS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 S MERIDIAN RD STE 150
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7960
Mailing Address - Country:US
Mailing Address - Phone:208-297-9495
Mailing Address - Fax:208-955-2490
Practice Address - Street 1:2825 S MERIDIAN RD STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7960
Practice Address - Country:US
Practice Address - Phone:208-297-9495
Practice Address - Fax:208-955-2490
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID348561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical