Provider Demographics
NPI:1083259063
Name:ROSE, TATIYANA RENAE
Entity Type:Individual
Prefix:
First Name:TATIYANA
Middle Name:RENAE
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TATIYANA
Other - Middle Name:RENAE ROSE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21120 MERIDIAN AVE E
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-8254
Mailing Address - Country:US
Mailing Address - Phone:253-414-7461
Mailing Address - Fax:
Practice Address - Street 1:21120 MERIDIAN AVE E
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338-8254
Practice Address - Country:US
Practice Address - Phone:253-414-7461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WACG61022955101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health