Provider Demographics
NPI:1093258212
Name:BRINSON, TARA LEIGH (CDP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LEIGH
Last Name:BRINSON
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 COLBY AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4022
Mailing Address - Country:US
Mailing Address - Phone:425-493-5310
Mailing Address - Fax:
Practice Address - Street 1:3019 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4022
Practice Address - Country:US
Practice Address - Phone:425-493-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-19
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00006297101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00006297OtherWASHINGTON STATE DEPARTMENT OF HEALTH