1578705950 NPI number — MRS. TESSA TARA WATERBURY WALLACE LCSW

Table of content: (NPI 1669932034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578705950 NPI number — MRS. TESSA TARA WATERBURY WALLACE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERBURY WALLACE
Provider First Name:
TESSA
Provider Middle Name:
TARA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578705950
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1519
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE SALMON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98672-1519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-493-2133
Provider Business Mailing Address Fax Number:
509-493-9544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
65371 HWY 14
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE SALMON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98672-9867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-493-2133
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  858LCSW , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: L4499 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 218112 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com