Provider Demographics
NPI:1952834095
Name:TANG, MAVERICK MIRIAM (CDPT)
Entity Type:Individual
Prefix:
First Name:MAVERICK
Middle Name:MIRIAM
Last Name:TANG
Suffix:
Gender:M
Credentials:CDPT
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:
Other - Last Name:TANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1610 LINCOLN ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-6252
Mailing Address - Country:US
Mailing Address - Phone:206-453-8501
Mailing Address - Fax:
Practice Address - Street 1:515 LAKEWAY DR
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5233
Practice Address - Country:US
Practice Address - Phone:360-676-2187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60993506101YA0400X
WACO 60713641101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)