Provider Demographics
NPI:1578039566
Name:AXTELL, TAMARA LYNN (LMHCA, CDPT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LYNN
Last Name:AXTELL
Suffix:
Gender:F
Credentials:LMHCA, CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22625 SE 281ST ST
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-8108
Mailing Address - Country:US
Mailing Address - Phone:503-317-6619
Mailing Address - Fax:
Practice Address - Street 1:30741 3RD AVE STE 163
Practice Address - Street 2:
Practice Address - City:BLACK DIAMOND
Practice Address - State:WA
Practice Address - Zip Code:98010-9791
Practice Address - Country:US
Practice Address - Phone:425-429-7673
Practice Address - Fax:425-207-4909
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61032658101YM0800X
WAMC60880555101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health