Provider Demographics
NPI:1699075606
Name:MAPLE LEAF HEALING ARTS CLINIC
Entity type:Organization
Organization Name:MAPLE LEAF HEALING ARTS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CLEVENGER
Authorized Official - Suffix:
Authorized Official - Credentials:LMP, LAC
Authorized Official - Phone:206-595-4512
Mailing Address - Street 1:9200 ROOSEVELT WAY NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115
Mailing Address - Country:US
Mailing Address - Phone:206-595-4512
Mailing Address - Fax:
Practice Address - Street 1:9200 ROOSEVELT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2842
Practice Address - Country:US
Practice Address - Phone:206-527-4568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00002247171100000X
WAMA00011147174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty