Provider Demographics
NPI:1417003658
Name:TIPHARETH, LAUREL SYLVAN (LM, LICSW, RN, ARNP)
Entity Type:Individual
Prefix:MS
First Name:LAUREL
Middle Name:SYLVAN
Last Name:TIPHARETH
Suffix:
Gender:F
Credentials:LM, LICSW, RN, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 HORSESHOE BEND RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98613-2302
Mailing Address - Country:US
Mailing Address - Phone:509-322-6254
Mailing Address - Fax:
Practice Address - Street 1:477 HORSESHOE BEND RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:WA
Practice Address - Zip Code:98613-2302
Practice Address - Country:US
Practice Address - Phone:509-322-6254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW600135761041C0700X
WAMW00000178176B00000X
WAAP61472750367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7071459Medicaid
14274779575OtherGROUP NPI
G8897057Medicare UPIN