Provider Demographics
NPI:1891270153
Name:TENNISON, THEODORE BRYAN (CDPT)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:BRYAN
Last Name:TENNISON
Suffix:
Gender:M
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 CENTER ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-8210
Practice Address - Country:US
Practice Address - Phone:253-280-9860
Practice Address - Fax:253-280-9870
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61071467101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)