Provider Demographics
NPI:1598242901
Name:SANDALL, TAMMRA LYNN (CP00005903)
Entity Type:Individual
Prefix:
First Name:TAMMRA
Middle Name:LYNN
Last Name:SANDALL
Suffix:
Gender:F
Credentials:CP00005903
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 BEAUDRY RD
Mailing Address - Street 2:
Mailing Address - City:MOXEE
Mailing Address - State:WA
Mailing Address - Zip Code:98936-9425
Mailing Address - Country:US
Mailing Address - Phone:509-930-7478
Mailing Address - Fax:
Practice Address - Street 1:2900 BEAUDRY RD
Practice Address - Street 2:
Practice Address - City:MOXEE
Practice Address - State:WA
Practice Address - Zip Code:98936-9425
Practice Address - Country:US
Practice Address - Phone:509-930-7478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00005903101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)