Healthcare Provider Details

I. General information

NPI: 1255907416
Provider Name (Legal Business Name): KATE MARIE TANNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 STEELHAMMER LN
CENTRALIA WA
98531
US

IV. Provider business mailing address

3510 STEELHAMMER LN
CENTRALIA WA
98531
US

V. Phone/Fax

Practice location:
  • Phone: 360-623-8020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: