Provider Demographics
NPI:1053825422
Name:DEHAVEN, DEBORAH RAE (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:RAE
Last Name:DEHAVEN
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:MISS
Other - First Name:DEBORAH
Other - Middle Name:RAE
Other - Last Name:MCMILLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED DIETITIAN
Mailing Address - Street 1:1901 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17700 SE 272ND ST STE 300
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4951
Practice Address - Country:US
Practice Address - Phone:253-372-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI654133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADI654OtherREGISTERED DIETITIAN