Provider Demographics
NPI:1295205060
Name:LEAVELL, MICAELA (LMT, MSW, LICSW)
Entity type:Individual
Prefix:
First Name:MICAELA
Middle Name:
Last Name:LEAVELL
Suffix:
Gender:F
Credentials:LMT, MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20115 FOREST PARK DR NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1152
Mailing Address - Country:US
Mailing Address - Phone:425-577-4055
Mailing Address - Fax:
Practice Address - Street 1:21907 64TH AVE W STE 200
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-6200
Practice Address - Country:US
Practice Address - Phone:425-679-9295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60908528225700000X
WALW615104161041C0700X
WASC610903081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE