1508404799 NPI number — LETA MAILE LAWHEAD MSW, LICSWA

Table of content: LETA MAILE LAWHEAD MSW, LICSWA (NPI 1508404799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508404799 NPI number — LETA MAILE LAWHEAD MSW, LICSWA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAWHEAD
Provider First Name:
LETA
Provider Middle Name:
MAILE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSWA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508404799
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1613
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORKS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-981-9809
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 BOGACHIEL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORKS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98331-9120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-327-8334
Provider Business Practice Location Address Fax Number:
360-374-9266
Provider Enumeration Date:
12/18/2019

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: 1041C0700X , with the licence number:  60998669 , 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)





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