Healthcare Provider Details

I. General information

NPI: 1154828770
Provider Name (Legal Business Name): DEVELOP MINDED THERAPIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 S TYLER ST STE 9
TACOMA WA
98409-2143
US

IV. Provider business mailing address

4040 S TYLER ST STE 9
TACOMA WA
98409-2143
US

V. Phone/Fax

Practice location:
  • Phone: 253-750-2664
  • Fax: 253-215-4426
Mailing address:
  • Phone: 253-750-2664
  • Fax: 253-215-4426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM1000X
TaxonomyMigrant Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DATHAN LANE
Title or Position: OWNER
Credential:
Phone: 253-750-2664