Provider Demographics
NPI:1093995037
Name:TAIT, SHANNON M
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:TAIT
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 1:16150 NE 85TH ST STE 222B
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3546
Mailing Address - Country:US
Mailing Address - Phone:425-202-7802
Mailing Address - Fax:425-821-0313
Practice Address - Street 1:16150 NE 85TH ST STE 222B
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3546
Practice Address - Country:US
Practice Address - Phone:425-202-7802
Practice Address - Fax:425-821-0313
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00052034101Y00000X
WALF60074427106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor