Healthcare Provider Details

I. General information

NPI: 1134854417
Provider Name (Legal Business Name): TAYA M WALLENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E COLLEGE WAY
MOUNT VERNON WA
98273-5612
US

IV. Provider business mailing address

4905 61ST DR NE
MARYSVILLE WA
98270-7552
US

V. Phone/Fax

Practice location:
  • Phone: 206-461-4880
  • Fax:
Mailing address:
  • Phone: 425-903-1361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: