Provider Demographics
NPI:1003126558
Name:REBOULET, TAURELL (LMP)
Entity Type:Individual
Prefix:MR
First Name:TAURELL
Middle Name:
Last Name:REBOULET
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:MR
Other - First Name:TAURELL
Other - Middle Name:
Other - Last Name:REBOULET
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:21514 82ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-9737
Mailing Address - Country:US
Mailing Address - Phone:360-333-9887
Mailing Address - Fax:
Practice Address - Street 1:21514 82ND AVE SE
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-9737
Practice Address - Country:US
Practice Address - Phone:360-333-9887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00023581171W00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health