Provider Demographics
NPI:1366758864
Name:DAVELAAR, MAILE GRACE (LMFT)
Entity type:Individual
Prefix:
First Name:MAILE
Middle Name:GRACE
Last Name:DAVELAAR
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MAILE
Other - Middle Name:GRACE
Other - Last Name:WOODIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9041 DERBY CANYON RD
Mailing Address - Street 2:
Mailing Address - City:PESHASTIN
Mailing Address - State:WA
Mailing Address - Zip Code:98847-9754
Mailing Address - Country:US
Mailing Address - Phone:509-679-8749
Mailing Address - Fax:
Practice Address - Street 1:10090 MAIN ST APT H
Practice Address - Street 2:
Practice Address - City:PESHASTIN
Practice Address - State:WA
Practice Address - Zip Code:98847-9770
Practice Address - Country:US
Practice Address - Phone:509-676-6009
Practice Address - Fax:509-676-6009
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-23
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF60195205106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2050159Medicaid