Basic Information
| Provider Information | |||||||||
| NPI: | 1346546918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CISSELL | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, CDP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEHRER | ||||||||
| OtherFirstName: | TAMARA | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW, CDP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1492 | ||||||||
| Address2: | |||||||||
| City: | STEVENSON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986481492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094273850 | ||||||||
| FaxNumber: | 5094270188 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 SW ROCK CREEK DR | ||||||||
| Address2: | |||||||||
| City: | STEVENSON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986484418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094273850 | ||||||||
| FaxNumber: | 5094270188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2011 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP60199613 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | LW60280965 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.