Provider Demographics
NPI:1578151445
Name:DELAVAN, CHARLIE (MS)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:DELAVAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 NE 128TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-4228
Mailing Address - Country:US
Mailing Address - Phone:916-704-3054
Mailing Address - Fax:
Practice Address - Street 1:1818 WESTLAKE AVE N STE 312
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-2707
Practice Address - Country:US
Practice Address - Phone:206-745-2764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG60820343106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist