Basic Information
| Provider Information | |||||||||
| NPI: | 1699722975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 ORONDO AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096626000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 317 E JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | CHELAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988162920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096826000 | ||||||||
| FaxNumber: | 5096826296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY00003727 | WA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 8483430 | 05 | WA | MEDICAID |