Basic Information
| Provider Information | |||||||||
| NPI: | 1972925568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAELEY | ||||||||
| FirstName: | TRISTAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.S. LBA DCR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 S 2ND ST # 1 | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982734209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604193640 | ||||||||
| FaxNumber: | 3604193535 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 S 2ND ST # 1 | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982734209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604193640 | ||||||||
| FaxNumber: | 3604193535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2014 | ||||||||
| LastUpdateDate: | 03/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-15-19009 | WA | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | BA60791227 | WA | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 101Y00000X | CG60242504 | WA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.