Healthcare Provider Details

I. General information

NPI: 1699075606
Provider Name (Legal Business Name): MAPLE LEAF HEALING ARTS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 ROOSEVELT WAY NE
SEATTLE WA
98115-2842
US

IV. Provider business mailing address

9200 ROOSEVELT WAY NE
SEATTLE WA
98115
US

V. Phone/Fax

Practice location:
  • Phone: 206-527-4568
  • Fax:
Mailing address:
  • Phone: 206-595-4512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00002247
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA00011147
License Number StateWA

VIII. Authorized Official

Name: GAIL MICHELLE CLEVENGER
Title or Position: OWNER
Credential: L.M.P., L.AC.
Phone: 206-595-4512