Provider Demographics
NPI:1477113777
Name:MIKE, TRISTAN B (CBT)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:B
Last Name:MIKE
Suffix:
Gender:F
Credentials:CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 EVERGREEN PARK DR SW APT 20
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5922
Mailing Address - Country:US
Mailing Address - Phone:503-409-8115
Mailing Address - Fax:
Practice Address - Street 1:4301 S PINE ST STE 505
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7208
Practice Address - Country:US
Practice Address - Phone:253-292-4354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
WACB60907782106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst