Provider Demographics
NPI:1508392663
Name:THETFORD, CALEB LEE (LMHC, MHP, CMHS, MA)
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:LEE
Last Name:THETFORD
Suffix:
Gender:M
Credentials:LMHC, MHP, CMHS, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 GLENN RD N
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-9767
Mailing Address - Country:US
Mailing Address - Phone:360-500-6743
Mailing Address - Fax:
Practice Address - Street 1:61 GLENN RD N
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-9767
Practice Address - Country:US
Practice Address - Phone:360-500-6743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC 60637837101YM0800X
WALH60855835101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health