Provider Demographics
NPI:1821564063
Name:FIREWEED THERAPY, PLLC
Entity type:Organization
Organization Name:FIREWEED THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAILE
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:DAVELAAR
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:509-676-6009
Mailing Address - Street 1:9041 DERBY CANYON RD
Mailing Address - Street 2:
Mailing Address - City:PESHASTIN
Mailing Address - State:WA
Mailing Address - Zip Code:98847-9754
Mailing Address - Country:US
Mailing Address - Phone:509-679-8749
Mailing Address - Fax:
Practice Address - Street 1:10090 MAIN ST APT H
Practice Address - Street 2:
Practice Address - City:PESHASTIN
Practice Address - State:WA
Practice Address - Zip Code:98847-9770
Practice Address - Country:US
Practice Address - Phone:509-676-6009
Practice Address - Fax:509-676-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1366758864OtherPERSONAL NPI
WA2050159Medicaid