Provider Demographics
NPI:1124563911
Name:MAPLE LEAF DBT, PLLC
Entity Type:Organization
Organization Name:MAPLE LEAF DBT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD TEACHER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GOETTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MA LMHC
Authorized Official - Phone:206-372-8400
Mailing Address - Street 1:229 BROADWAY E
Mailing Address - Street 2:ROOM 8
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-5787
Mailing Address - Country:US
Mailing Address - Phone:206-372-8400
Mailing Address - Fax:
Practice Address - Street 1:229 BROADWAY E
Practice Address - Street 2:ROOM 8
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-5787
Practice Address - Country:US
Practice Address - Phone:206-372-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004179101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty