Provider Demographics
NPI:1003020090
Name:ANDERSON, TANA (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:TANA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:TANA
Other - Middle Name:RAE ANDERSON
Other - Last Name:FORTINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LMHC
Mailing Address - Street 1:15600 REDMOND WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3862
Mailing Address - Country:US
Mailing Address - Phone:425-802-7146
Mailing Address - Fax:425-836-2517
Practice Address - Street 1:15600 REDMOND WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3862
Practice Address - Country:US
Practice Address - Phone:425-802-7146
Practice Address - Fax:425-836-2517
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004575101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA603-017-092OtherUBI
27-2664116OtherFEDERAL TAX EIN