Provider Demographics
NPI:1508586678
Name:TIENHAARA, BRYAN RANDALL
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:RANDALL
Last Name:TIENHAARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 BOBCAT LN
Mailing Address - Street 2:
Mailing Address - City:MOSSYROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98564-5102
Mailing Address - Country:US
Mailing Address - Phone:360-520-5335
Mailing Address - Fax:
Practice Address - Street 1:320 6TH ST
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-2503
Practice Address - Country:US
Practice Address - Phone:360-915-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst