Provider Demographics
NPI:1689230401
Name:PRATT, CARLEIGH MARIE CAMERON
Entity Type:Individual
Prefix:
First Name:CARLEIGH
Middle Name:MARIE CAMERON
Last Name:PRATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLEIGH
Other - Middle Name:MARIE
Other - Last Name:CAMERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6004 CAPITOL BLVD SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-8520
Practice Address - Country:US
Practice Address - Phone:360-704-7580
Practice Address - Fax:360-704-7567
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF61330299106H00000X
WAMG61077242101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2135081Medicaid