Provider Demographics
NPI:1235413055
Name:MATTHIAS, CHARISSA GRACE
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:GRACE
Last Name:MATTHIAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARISSA
Other - Middle Name:GRACE
Other - Last Name:HULET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-3335
Mailing Address - Fax:206-764-0489
Practice Address - Street 1:1516 S 11TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3332
Practice Address - Country:US
Practice Address - Phone:253-396-1634
Practice Address - Fax:253-396-1663
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60192126101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor