Provider Demographics
NPI:1972930790
Name:GLEASON, TANYA FAYE (CDPT)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:FAYE
Last Name:GLEASON
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2569
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98213-0569
Mailing Address - Country:US
Mailing Address - Phone:425-212-4200
Mailing Address - Fax:
Practice Address - Street 1:811 MADISON ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-4543
Practice Address - Country:US
Practice Address - Phone:425-212-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60366272101YA0400X
WACG60508273101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor