Provider Demographics
NPI:1154533164
Name:TILLOTSON, SUZANNA MARIE (PHD)
Entity type:Individual
Prefix:MS
First Name:SUZANNA
Middle Name:MARIE
Last Name:TILLOTSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3257 CATALINA LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-4006
Mailing Address - Country:US
Mailing Address - Phone:208-672-8130
Mailing Address - Fax:208-672-8130
Practice Address - Street 1:1701 N BEACH ST
Practice Address - Street 2:#2
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1117
Practice Address - Country:US
Practice Address - Phone:208-672-8130
Practice Address - Fax:208-672-8130
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT - 11106H00000X
UT116424-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist