Provider Demographics
NPI:1811381403
Name:VAN TASSELL, KATIE MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:VAN TASSELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 S ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3201
Mailing Address - Country:US
Mailing Address - Phone:571-606-0792
Mailing Address - Fax:
Practice Address - Street 1:2114 S ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3201
Practice Address - Country:US
Practice Address - Phone:571-606-0792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5599101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health