Provider Demographics
NPI:1881208866
Name:MINCKLER, TARYN NICOLE
Entity Type:Individual
Prefix:
First Name:TARYN
Middle Name:NICOLE
Last Name:MINCKLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N STATE ST APT 206
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5356
Mailing Address - Country:US
Mailing Address - Phone:360-970-9831
Mailing Address - Fax:
Practice Address - Street 1:4201 MERIDIAN ST STE 113
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-5532
Practice Address - Country:US
Practice Address - Phone:360-305-3275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61021533106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician