Provider Demographics
NPI:1851026678
Name:MAUSSHARDT, THEODORE ROBERT
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:ROBERT
Last Name:MAUSSHARDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 CLINTON PL
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4609
Mailing Address - Country:US
Mailing Address - Phone:425-258-4933
Mailing Address - Fax:
Practice Address - Street 1:1112 CLINTON PL
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4609
Practice Address - Country:US
Practice Address - Phone:425-258-4933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACL60151323101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health