Basic Information
| Provider Information | |||||||||
| NPI: | 1578705950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERBURY WALLACE | ||||||||
| FirstName: | TESSA | ||||||||
| MiddleName: | TARA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1519 | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986721519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094932133 | ||||||||
| FaxNumber: | 5094939544 | ||||||||
| Practice Location | |||||||||
| Address1: | 65371 HWY 14 | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986729867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094932133 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2009 | ||||||||
| LastUpdateDate: | 11/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 858LCSW | MT | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | L4499 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 218112 | 05 | OR | MEDICAID |