Provider Demographics
NPI:1649953704
Name:MEIJOME, MADDISON CAPRI (LSWAIC)
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:CAPRI
Last Name:MEIJOME
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:MADDISON
Other - Middle Name:CAPRI
Other - Last Name:HAUETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5407 W 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-7549
Mailing Address - Country:US
Mailing Address - Phone:509-948-7023
Mailing Address - Fax:
Practice Address - Street 1:5407 W 17TH AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338-7549
Practice Address - Country:US
Practice Address - Phone:509-948-7023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC610209831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical