1467815639 NPI number — ALISSA ANDREA MORTENSON TYKA MA, LMHCA

Table of content: NICOLE ALINE PAVY RN (NPI 1770013385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467815639 NPI number — ALISSA ANDREA MORTENSON TYKA MA, LMHCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORTENSON TYKA
Provider First Name:
ALISSA
Provider Middle Name:
ANDREA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LMHCA
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:
1467815639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 17TH AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98112-3924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-218-8860
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2763 152ND AVE NE
Provider Second Line Business Practice Location Address:
BUILDING 4A
Provider Business Practice Location Address City Name:
REDMOND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98052-5555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-628-2763
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2016

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: 101YM0800X , with the licence number:  MC 60644454 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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