=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386211894
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TFD CARES/BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2021
-----------------------------------------------------
Last Update Date | 06/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 FAWCETT AVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98402-5605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-591-5737
-----------------------------------------------------
Fax | 253-591-5746
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 FAWCETT AVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98402-5605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-591-5737
-----------------------------------------------------
Fax | 253-591-5737
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEAD CSR
-----------------------------------------------------
Name | SHANNON COLLAZO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-591-2044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------