Provider Demographics
NPI:1083188007
Name:TETRAULT, TIMOTHY LANCE (LMHC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LANCE
Last Name:TETRAULT
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2743 CALIFORNIA AVE SW UNIT 301
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-2495
Mailing Address - Country:US
Mailing Address - Phone:206-450-3167
Mailing Address - Fax:
Practice Address - Street 1:2743 CALIFORNIA AVE SW UNIT 301
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-2495
Practice Address - Country:US
Practice Address - Phone:206-450-3167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-12
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60192134101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty