=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174895650
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA MOLINE-MYGATT TULIAO LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2012
-----------------------------------------------------
Last Update Date | 12/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9505 S STEELE ST
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98444-1858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-597-6800
-----------------------------------------------------
Fax | 253-597-6888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19174 133RD ST E
-----------------------------------------------------
City | BONNEY LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98391-5505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-917-1383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------