Provider Demographics
NPI:1790667111
Name:QUEEN, TYTEISHA (MSW, LSWAIC)
Entity type:Individual
Prefix:
First Name:TYTEISHA
Middle Name:
Last Name:QUEEN
Suffix:
Gender:F
Credentials:MSW, LSWAIC
Other - Prefix:
Other - First Name:IRIS
Other - Middle Name:
Other - Last Name:QUEEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LSWAIC
Mailing Address - Street 1:12039 MINNIE ROSE LN NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-7503
Mailing Address - Country:US
Mailing Address - Phone:206-595-6223
Mailing Address - Fax:
Practice Address - Street 1:12039 MINNIE ROSE LN NE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-7503
Practice Address - Country:US
Practice Address - Phone:206-595-6223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC616869611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical