Provider Demographics
NPI:1912316571
Name:DETHLEFS, MADELYN JOAN
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:JOAN
Last Name:DETHLEFS
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 1:6419 32ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9519
Mailing Address - Country:US
Mailing Address - Phone:509-939-0475
Mailing Address - Fax:
Practice Address - Street 1:6419 32ND AVE NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-9519
Practice Address - Country:US
Practice Address - Phone:509-939-0475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist