Provider Demographics
NPI:1194182030
Name:PALLASCH, TINA LOUISE (BA, CDP)
Entity type:Individual
Prefix:
First Name:TINA LOUISE
Middle Name:
Last Name:PALLASCH
Suffix:
Gender:F
Credentials:BA, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 WETMORE AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2927
Mailing Address - Country:US
Mailing Address - Phone:425-595-6769
Mailing Address - Fax:
Practice Address - Street 1:2610 WETMORE AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-2927
Practice Address - Country:US
Practice Address - Phone:425-258-5270
Practice Address - Fax:425-258-5275
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO 60561840101YA0400X
WACP60788538101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)