Healthcare Provider Details

I. General information

NPI: 1548777964
Provider Name (Legal Business Name): ALEXANDRIA DEATHERAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8815 S TACOMA WAY STE 122
LAKEWOOD WA
98499-7011
US

IV. Provider business mailing address

22910 SE 281ST PL
MAPLE VALLEY WA
98038-8135
US

V. Phone/Fax

Practice location:
  • Phone: 253-682-0320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: