Provider Demographics
NPI:1073002028
Name:LOEFFLER, CHYNNA LEILA FUJIKO (MAP)
Entity Type:Individual
Prefix:
First Name:CHYNNA
Middle Name:LEILA FUJIKO
Last Name:LOEFFLER
Suffix:
Gender:F
Credentials:MAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4526 FEDERAL AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2132
Mailing Address - Country:US
Mailing Address - Phone:425-349-8241
Mailing Address - Fax:
Practice Address - Street 1:4526 FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2132
Practice Address - Country:US
Practice Address - Phone:425-349-8241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2021-09-07
Deactivation Date:2019-10-07
Deactivation Code:
Reactivation Date:2019-10-17
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X, 101YM0800X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60871956Medicaid