Provider Demographics
NPI:1699049304
Name:MARTIN, TANYA KEHAULANI (LICSW)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:KEHAULANI
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:KEHAULANI
Other - Last Name:KOLLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-414-2236
Mailing Address - Fax:360-414-2788
Practice Address - Street 1:600 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3256
Practice Address - Country:US
Practice Address - Phone:360-414-2236
Practice Address - Fax:360-414-2788
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60156645104100000X
WALW602471281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker