Provider Demographics
NPI:1093842643
Name:ETTLIN, TARA (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ETTLIN
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 IRON ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4123
Mailing Address - Country:US
Mailing Address - Phone:360-734-2664
Mailing Address - Fax:360-671-8006
Practice Address - Street 1:2110 IRON ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4123
Practice Address - Country:US
Practice Address - Phone:360-734-2664
Practice Address - Fax:360-671-8006
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60031137101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7406051Medicaid