Healthcare Provider Details

I. General information

NPI: 1184762916
Provider Name (Legal Business Name): ANTHONY ITTNER TERNDRUP LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W STEWART RD STE 108
MOUNT VERNON WA
98273-9607
US

IV. Provider business mailing address

PO BOX 93
DEER HARBOR WA
98243-0093
US

V. Phone/Fax

Practice location:
  • Phone: 360-340-9874
  • Fax:
Mailing address:
  • Phone: 360-230-8388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberFELLOW6813
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC1233
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0367
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: