Provider Demographics
NPI:1932614617
Name:TIRTOMIHARDJO, FLANNERY ANABELL
Entity Type:Individual
Prefix:
First Name:FLANNERY
Middle Name:ANABELL
Last Name:TIRTOMIHARDJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 W FULTON ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-2269
Mailing Address - Country:US
Mailing Address - Phone:425-923-0821
Mailing Address - Fax:
Practice Address - Street 1:4746 11TH AVE NE # 112
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4657
Practice Address - Country:US
Practice Address - Phone:206-535-8876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst