Provider Demographics
NPI:1972925568
Name:DAELEY, TRISTAN (MS LBA DCR)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:DAELEY
Suffix:
Gender:M
Credentials:MS LBA DCR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S 2ND ST # 1
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-4209
Mailing Address - Country:US
Mailing Address - Phone:360-419-3640
Mailing Address - Fax:360-419-3535
Practice Address - Street 1:1100 S 2ND ST # 1
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4209
Practice Address - Country:US
Practice Address - Phone:360-419-3640
Practice Address - Fax:360-419-3535
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60242504101Y00000X
WABA60791227103K00000X
WA1-15-19009103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor