MEDICARE: MAPLE LEAF MENTAL HEALTH PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist

General Provider Information

NPI Number	:	1407689037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE LEAF MENTAL HEALTH PLLC

Provider Business Mailing Address
First Line	:	PO BOX 75018
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98175-0018
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9706 4TH AVE NE STE 320
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-2199
Country	:	US
Telephone Number	:	206-814-1455
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CONOR BYRNE
Credential	:
Telephone Number	:	443-745-9333

Provider Enumeration Date	:	08/20/2024
Last Update Date	:	08/20/2024

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