Provider Demographics
NPI:1568970283
Name:TRACE, JULIA MADALYN (CG60825062)
Entity Type:Individual
Prefix:MS
First Name:JULIA
Middle Name:MADALYN
Last Name:TRACE
Suffix:
Gender:F
Credentials:CG60825062
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98134-2417
Mailing Address - Country:US
Mailing Address - Phone:206-832-8518
Mailing Address - Fax:
Practice Address - Street 1:210 S HUDSON ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134
Practice Address - Country:US
Practice Address - Phone:206-832-8518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1114367521Medicaid