Provider Demographics
NPI:1932524162
Name:WITSIL, EMILY T (LMT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:T
Last Name:WITSIL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 W HAYS ST APT 7
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5557
Mailing Address - Country:US
Mailing Address - Phone:302-745-4714
Mailing Address - Fax:208-853-5518
Practice Address - Street 1:9217 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-1737
Practice Address - Country:US
Practice Address - Phone:208-853-7221
Practice Address - Fax:208-853-5518
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-1526225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMAS-1526OtherSTATE OF IDAHO