Provider Demographics
NPI:1619689189
Name:SMITH, TESSA VICTORIA RUBY (MA)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:VICTORIA RUBY
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5129 88TH ST NE UNIT A
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-2617
Mailing Address - Country:US
Mailing Address - Phone:425-328-9368
Mailing Address - Fax:
Practice Address - Street 1:102 E MAIN ST STE 7
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1538
Practice Address - Country:US
Practice Address - Phone:425-328-9368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61388206101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health