Provider Demographics
NPI:1275114746
Name:NELSON, TANYA RENE (CPS/ RAC)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:RENE
Last Name:NELSON
Suffix:
Gender:F
Credentials:CPS/ RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W BOONE AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-5029
Mailing Address - Country:US
Mailing Address - Phone:509-325-7232
Mailing Address - Fax:
Practice Address - Street 1:910 W BOONE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-5029
Practice Address - Country:US
Practice Address - Phone:509-325-7232
Practice Address - Fax:509-325-4580
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WANA61148913OtherN.A. R.