Provider Demographics
NPI:1356754535
Name:TARVER, TINA (BCBA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:TARVER
Suffix:
Gender:F
Credentials:BCBA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 DONOVAN AVE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-7325
Mailing Address - Country:US
Mailing Address - Phone:360-393-5746
Mailing Address - Fax:
Practice Address - Street 1:1104 DONOVAN AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-7325
Practice Address - Country:US
Practice Address - Phone:425-429-4793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-15-20651103K00000X
WALL 00004760235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALL 00004760OtherDEPARTMENT OF HEALTH