Provider Demographics
NPI:1548250533
Name:TAFT, TERESA (MSW LICSW)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:TAFT
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:TESS
Other - Middle Name:
Other - Last Name:KISTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3868
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12615 E MISSION AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1047
Practice Address - Country:US
Practice Address - Phone:509-228-1200
Practice Address - Fax:509-252-9300
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000042781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
7655221OtherAETNA
2687TAOtherASURIS NW HEALTH
000010148106OtherBLUE SHIELD OF IDAHO
G8801402Medicare PIN
R89195Medicare UPIN