Provider Demographics
NPI:1912997800
Name:TINDALL, ANGELIQUE GRAYSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANGELIQUE
Middle Name:GRAYSON
Last Name:TINDALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:EVELYN
Other - Middle Name:ANGELIQUE
Other - Last Name:GRAYSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 30248
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-3004
Mailing Address - Country:US
Mailing Address - Phone:509-768-4248
Mailing Address - Fax:509-343-0504
Practice Address - Street 1:1120 N. PINES
Practice Address - Street 2:SUITE C
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99206-4942
Practice Address - Country:US
Practice Address - Phone:509-768-4248
Practice Address - Fax:509-343-0504
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001825103G00000X, 103TH0100X, 103TR0400X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0165817OtherLABOR & INDUSTRIES
WA0165817OtherLABOR & INDUSTRIES
WA503025Medicare ID - Type Unspecified
S41752Medicare UPIN