Provider Demographics
NPI:1396381083
Name:WIRKKALA, TYSHA MARIE
Entity Type:Individual
Prefix:MRS
First Name:TYSHA
Middle Name:MARIE
Last Name:WIRKKALA
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 1:2814 234TH LN
Mailing Address - Street 2:
Mailing Address - City:OCEAN PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98640-3710
Mailing Address - Country:US
Mailing Address - Phone:360-642-3737
Mailing Address - Fax:
Practice Address - Street 1:2204 PACIFIC AVE N
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631-3300
Practice Address - Country:US
Practice Address - Phone:360-642-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health