Provider Demographics
NPI:1649837576
Name:KAFEL, TIERRA EMMALY
Entity type:Individual
Prefix:
First Name:TIERRA
Middle Name:EMMALY
Last Name:KAFEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:EMMALY
Other - Last Name:KAFEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:122 INDIGO CT
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-1882
Mailing Address - Country:US
Mailing Address - Phone:360-846-7952
Mailing Address - Fax:
Practice Address - Street 1:9115 SW OLESON RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6876
Practice Address - Country:US
Practice Address - Phone:971-236-0915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-27
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAKAFELTE005MB106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA912196637OtherUNITEDHEALTHCARE