Provider Demographics
NPI:1033898507
Name:LOUSBERG, TANNER MICHELLE
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:MICHELLE
Last Name:LOUSBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6331 49TH DR NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4449
Mailing Address - Country:US
Mailing Address - Phone:360-348-1225
Mailing Address - Fax:
Practice Address - Street 1:6331 49TH DR NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4449
Practice Address - Country:US
Practice Address - Phone:360-348-1225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician