Provider Demographics
NPI:1578048062
Name:TENNISON, EBONIE MARIE (CDP)
Entity Type:Individual
Prefix:
First Name:EBONIE
Middle Name:MARIE
Last Name:TENNISON
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:EBONIE
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6700 MARTIN WAY E STE 117
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5586
Mailing Address - Country:US
Mailing Address - Phone:360-413-6910
Mailing Address - Fax:
Practice Address - Street 1:3101 S TACOMA WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-4717
Practice Address - Country:US
Practice Address - Phone:253-396-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61011133101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)