Healthcare Provider Details

I. General information

NPI: 1093995037
Provider Name (Legal Business Name): SHANNON M TAIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16150 NE 85TH ST STE 222B
REDMOND WA
98052-3546
US

IV. Provider business mailing address

16150 NE 85TH ST STE 222B
REDMOND WA
98052-3546
US

V. Phone/Fax

Practice location:
  • Phone: 425-202-7802
  • Fax: 425-821-0313
Mailing address:
  • Phone: 425-202-7802
  • Fax: 425-821-0313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberRC00052034
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLF60074427
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: