Healthcare Provider Details

I. General information

NPI: 1073012084
Provider Name (Legal Business Name): TENNILLE SUZANNE O'BLENNESS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2308 W 3RD AVE
SPOKANE WA
99201-5810
US

IV. Provider business mailing address

PO BOX 4627
SPOKANE WA
99220-0627
US

V. Phone/Fax

Practice location:
  • Phone: 509-624-1244
  • Fax: 509-624-6240
Mailing address:
  • Phone: 509-624-1244
  • Fax: 509-624-6240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60313150
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: