Provider Demographics
NPI:1790099455
Name:UTERMARK, TAMISHA LYNETTE (PHD)
Entity Type:Individual
Prefix:DR
First Name:TAMISHA
Middle Name:LYNETTE
Last Name:UTERMARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 WHITEWING LN
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-5997
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 ROCK PRAIRIE RD STE B
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8777
Practice Address - Country:US
Practice Address - Phone:979-255-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34194103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist