Provider Demographics
NPI:1538544192
Name:CHADDERDON, MICHELLE RAE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:CHADDERDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:REA
Other - Last Name:STANSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3214 W MCGRAW ST STE 212
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98199-3239
Mailing Address - Country:US
Mailing Address - Phone:206-453-4882
Mailing Address - Fax:
Practice Address - Street 1:3214 W MCGRAW ST STE 212
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-3239
Practice Address - Country:US
Practice Address - Phone:206-453-4882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60585475103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60585475OtherDEPARTMENT OF HEALTH