Provider Demographics
NPI:1689735904
Name:TISHKOFF, MYRA J (MS)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:J
Last Name:TISHKOFF
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10532A WHITMAN AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-8824
Mailing Address - Country:US
Mailing Address - Phone:206-841-4842
Mailing Address - Fax:
Practice Address - Street 1:17535 15TH AVE NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-3801
Practice Address - Country:US
Practice Address - Phone:206-440-9708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00003279235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist