Provider Demographics
NPI:1699247130
Name:LIGHTFOOT, TENNILLE ANNA (CP00005071)
Entity type:Individual
Prefix:
First Name:TENNILLE
Middle Name:ANNA
Last Name:LIGHTFOOT
Suffix:
Gender:F
Credentials:CP00005071
Other - Prefix:
Other - First Name:TENNILLE
Other - Middle Name:
Other - Last Name:CHAUSSEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14025 N KOTH RD
Mailing Address - Street 2:
Mailing Address - City:NEWMAN LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99025-9484
Mailing Address - Country:US
Mailing Address - Phone:509-954-7480
Mailing Address - Fax:
Practice Address - Street 1:3400 W GARLAND AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-2119
Practice Address - Country:US
Practice Address - Phone:509-325-2355
Practice Address - Fax:509-326-3370
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00005071101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP00005071Medicaid