=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508404799
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LETA MAILE LAWHEAD MSW, LICSWA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2019
-----------------------------------------------------
Last Update Date | 12/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 530 BOGACHIEL WAY
-----------------------------------------------------
City | FORKS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98331-9120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-327-8334
-----------------------------------------------------
Fax | 360-374-9266
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 1613
-----------------------------------------------------
City | FORKS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-981-9809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 60998669
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------