Basic Information
| Provider Information | |||||||||
| NPI: | 1023257094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOZNIAK | ||||||||
| FirstName: | TRISTAN | ||||||||
| MiddleName: | SHANNON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. LMHC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHNEIDER | ||||||||
| OtherFirstName: | TRISTAN | ||||||||
| OtherMiddleName: | SHANNON PIXLEY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 26 FLANDERSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | CATHLAMET | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986129541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602706128 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 945 11TH AVE STE B | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604148600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2009 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LH60887869 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2124444 | 05 | WA | MEDICAID |