1366758864 NPI number — MAILE GRACE DAVELAAR LMFT

Table of content: MAILE GRACE DAVELAAR LMFT (NPI 1366758864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366758864 NPI number — MAILE GRACE DAVELAAR LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVELAAR
Provider First Name:
MAILE
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOODIN
Provider Other First Name:
MAILE
Provider Other Middle Name:
GRACE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366758864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9041 DERBY CANYON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PESHASTIN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98847-9754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-679-8749
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10090 MAIN ST APT H
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PESHASTIN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98847-9770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-676-6009
Provider Business Practice Location Address Fax Number:
509-676-6009
Provider Enumeration Date:
08/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  LF60195205 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2050159 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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