MEDICARE: DR. ANGELIQUE GRAYSON TINDALL PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PY00001825	WA
2	103TH0100X	Health Service Psychologist	PY00001825	WA
3	103TR0400X	Rehabilitation Psychologist	PY00001825	WA
4	103T00000X	Psychologist	PY00001825	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0165817	OTHER	WA	LABOR & INDUSTRIES

General Provider Information

NPI Number	:	1912997800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGELIQUE GRAYSON TINDALL PHD

Provider Business Mailing Address
First Line	:	PO BOX 30248
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99223-3004
Country	:	US
Telephone Number	:	509-768-4248
Fax Number	:	509-343-0504

Provider Business Practice Location Address
First Line	:	1120 N. PINES
Second Line	:	SUITE C
City	:	SPOKANE
State	:	WA
Zip	:	99206-4942
Country	:	US
Telephone Number	:	509-768-4248
Fax Number	:	509-343-0504

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	04/14/2009

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