Basic Information
Provider Information | |||||||||
NPI: | 1275608705 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TOLLAN | ||||||||
FirstName: | STEPHANIE | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROWE | ||||||||
OtherFirstName: | STEPHANIE | ||||||||
OtherMiddleName: | A. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OTR L | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1624 S I ST | ||||||||
Address2: | SUITE 301 | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984055016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2534288292 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1624 S I ST | ||||||||
Address2: | SUITE 301 | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984055016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2534288292 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2006 | ||||||||
LastUpdateDate: | 04/22/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT00002718 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 169249 | 01 | WA | LABOR AND INDUSTRIES | OTHER | 5871TO | 01 | WA | REGENCE BCBS TACOMA | OTHER | 7472TO | 01 | WA | REGENCE BCBS GIG HARBOR | OTHER | 8369340 | 05 | WA |   | MEDICAID |