Healthcare Provider Details

I. General information

NPI: 1912997800
Provider Name (Legal Business Name): ANGELIQUE GRAYSON TINDALL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. EVELYN ANGELIQUE GRAYSON

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 N. PINES SUITE C
SPOKANE WA
99206-4942
US

IV. Provider business mailing address

PO BOX 30248
SPOKANE WA
99223-3004
US

V. Phone/Fax

Practice location:
  • Phone: 509-768-4248
  • Fax: 509-343-0504
Mailing address:
  • Phone: 509-768-4248
  • Fax: 509-343-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY00001825
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPY00001825
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPY00001825
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY00001825
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: