Provider Demographics
NPI:1104105097
Name:HLADIK, TANYA MARIE (LMP)
Entity type:Individual
Prefix:MISS
First Name:TANYA
Middle Name:MARIE
Last Name:HLADIK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N GARDEN ST APT 1D
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5440
Mailing Address - Country:US
Mailing Address - Phone:360-393-1708
Mailing Address - Fax:
Practice Address - Street 1:2430 CORNWALL AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-3415
Practice Address - Country:US
Practice Address - Phone:360-393-1708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60222049225700000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No374J00000XNursing Service Related ProvidersDoula