Healthcare Provider Details

I. General information

NPI: 1104128479
Provider Name (Legal Business Name): SEAN JEREMIAH TOLLISON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 S COLUMBIAN WAY MAIL STOP: S-116-DDTP
SEATTLE WA
98108-1532
US

IV. Provider business mailing address

415 1ST AVE N STE 200
SEATTLE WA
98109-4765
US

V. Phone/Fax

Practice location:
  • Phone: 206-764-2163
  • Fax: 206-761-2192
Mailing address:
  • Phone: 206-764-2163
  • Fax: 206-761-2192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: