Provider Demographics
NPI:1578705950
Name:WATERBURY WALLACE, TESSA TARA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TESSA
Middle Name:TARA
Last Name:WATERBURY WALLACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1519
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-1519
Mailing Address - Country:US
Mailing Address - Phone:509-493-2133
Mailing Address - Fax:509-493-9544
Practice Address - Street 1:65371 HWY 14
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672-9867
Practice Address - Country:US
Practice Address - Phone:509-493-2133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT858LCSW1041C0700X
ORL44991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218112Medicaid
OR383996Medicare Oscar/Certification