Provider Demographics
NPI:1548820087
Name:PALACIO, TISIEN WAWANI
Entity type:Individual
Prefix:
First Name:TISIEN
Middle Name:WAWANI
Last Name:PALACIO
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 1:5000 N WILLAMETTE BLVD RM 201
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5743
Mailing Address - Country:US
Mailing Address - Phone:916-580-4687
Mailing Address - Fax:
Practice Address - Street 1:1508 SW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-3312
Practice Address - Country:US
Practice Address - Phone:503-726-3690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health