Provider Demographics
NPI:1649934787
Name:JULIAN, MYAH ALEXANDRA
Entity type:Individual
Prefix:
First Name:MYAH
Middle Name:ALEXANDRA
Last Name:JULIAN
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 1:3202 S MASON AVE APT A305
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-8544
Mailing Address - Country:US
Mailing Address - Phone:253-325-2007
Mailing Address - Fax:
Practice Address - Street 1:3680 S CEDAR ST STE A
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-5728
Practice Address - Country:US
Practice Address - Phone:206-313-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA111524501Medicaid