Provider Demographics
NPI:1841828456
Name:PETERSON HENRY, DAESOLEIL
Entity type:Individual
Prefix:
First Name:DAESOLEIL
Middle Name:
Last Name:PETERSON HENRY
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 1:37509 SE FURY ST
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-9593
Mailing Address - Country:US
Mailing Address - Phone:661-714-3606
Mailing Address - Fax:
Practice Address - Street 1:8226 BRACKEN PL SE STE 200
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-2935
Practice Address - Country:US
Practice Address - Phone:425-842-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician