Provider Demographics
NPI:1174190581
Name:DE VAULT, CARRIE NICOLE (CPC, CPRC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:NICOLE
Last Name:DE VAULT
Suffix:
Gender:F
Credentials:CPC, CPRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 4TH AVE S APT 703
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-6645
Mailing Address - Country:US
Mailing Address - Phone:206-280-6312
Mailing Address - Fax:
Practice Address - Street 1:3805 108TH AVE NE STE 102
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-7613
Practice Address - Country:US
Practice Address - Phone:425-242-1713
Practice Address - Fax:833-474-6112
Is Sole Proprietor?:No
Enumeration Date:2021-06-06
Last Update Date:2021-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA171M00000X, 175T00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist