Individual
TANNA SUSAN WILLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LCMT
Contact information
Practice address
1529 BELMONT ST, BOISE, ID 83725-0001
(208) 426-1459
Mailing address
1910 UNIVERSITY DR, BOISE, ID 83725-1351
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
MAS-732
ID
261QS1000X
Student Health Clinic/Center
820290701
ID
Other
Enumeration date
07/19/2013
Last updated
07/19/2013
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