Provider Demographics
NPI:1619786498
Name:IBBERSON, TASHIANA MARIE (SUDPT, BA)
Entity type:Individual
Prefix:
First Name:TASHIANA
Middle Name:MARIE
Last Name:IBBERSON
Suffix:
Gender:F
Credentials:SUDPT, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11627 AIRPORT RD STE B
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-8714
Mailing Address - Country:US
Mailing Address - Phone:425-754-1543
Mailing Address - Fax:
Practice Address - Street 1:11627 AIRPORT RD STE B
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-8714
Practice Address - Country:US
Practice Address - Phone:425-754-1543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61515161101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)