Provider Demographics
NPI:1023465176
Name:TACKELS, TIMOTHY (CP 00002256)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:TACKELS
Suffix:
Gender:M
Credentials:CP 00002256
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E COLLEGE WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-5612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 E COLLEGE WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5612
Practice Address - Country:US
Practice Address - Phone:360-848-8437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 00002256101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)