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General NPI Number Information
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NPI Number | 1891270153
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Entity Type | Individual
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Provider Name | THEODORE BRYAN TENNISON CDPT
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Gender | Male
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Dates
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Enumeration Date | 10/02/2018
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Last Update Date | 10/19/2022
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Provider Practice Location Address
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Address Line | 1415 CENTER ST
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City | TACOMA
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State | WA
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Zip | 98409-8210
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Country | US
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Telephone | 253-280-9860
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Fax | 253-280-9870
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Provider Business Mailing Address
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Address Line | PO BOX 34703
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City | SEATTLE
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State | WA
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Zip | 98124-1703
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CP61071467
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License Number State | WA
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