Provider Demographics
NPI:1902533748
Name:MAYBACH, JOHANNAH LACY
Entity type:Individual
Prefix:
First Name:JOHANNAH
Middle Name:LACY
Last Name:MAYBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W MAGNOLIA ST STE 433
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4354
Mailing Address - Country:US
Mailing Address - Phone:970-769-9442
Mailing Address - Fax:
Practice Address - Street 1:114 W MAGNOLIA ST STE 433
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4354
Practice Address - Country:US
Practice Address - Phone:360-594-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF.61535423106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist