Basic Information
Provider Information | |||||||||
NPI: | 1558650499 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHATLEY | ||||||||
FirstName: | MACEE | ||||||||
MiddleName: | LANAE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2257 52ND AVE | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | WA | ||||||||
PostalCode: | 986326203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4254226160 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2801 LOMBARD AVE | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982013619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252123993 | ||||||||
FaxNumber: | 4252593073 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2011 | ||||||||
LastUpdateDate: | 04/25/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MC60146059 | WA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | LH60421721 | WA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.