Provider Demographics
NPI:1962042333
Name:MAULE, MCKENZIE L
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:L
Last Name:MAULE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 13TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-6674
Mailing Address - Country:US
Mailing Address - Phone:253-381-4089
Mailing Address - Fax:
Practice Address - Street 1:711 COMMERCE ST STE 204
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4514
Practice Address - Country:US
Practice Address - Phone:603-692-8173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARBT-20-110116106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician