Provider Demographics
NPI:1891823100
Name:TAGUE, TIA RAE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:TIA
Middle Name:RAE
Last Name:TAGUE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 W FRANCIS AVE UNIT 516
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-6512
Mailing Address - Country:US
Mailing Address - Phone:509-990-6104
Mailing Address - Fax:
Practice Address - Street 1:12422 E MANSFIELD AVE APT 90
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1167
Practice Address - Country:US
Practice Address - Phone:509-990-6104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
WAMA00018360174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical