Healthcare Provider Details

I. General information

NPI: 1255966354
Provider Name (Legal Business Name): TYE LEIGH SHELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 08/20/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 N MONROE ST
SPOKANE WA
99205-4545
US

IV. Provider business mailing address

2222 N MONROE ST
SPOKANE WA
99205-4545
US

V. Phone/Fax

Practice location:
  • Phone: 509-413-2950
  • Fax:
Mailing address:
  • Phone: 509-413-2950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC61451330
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: