Provider Demographics
NPI:1760286793
Name:TAKULYABWANI, DEOTILA LUCAS
Entity type:Individual
Prefix:
First Name:DEOTILA
Middle Name:LUCAS
Last Name:TAKULYABWANI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26616 WEBSTER RD E
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-7318
Mailing Address - Country:US
Mailing Address - Phone:360-402-5946
Mailing Address - Fax:
Practice Address - Street 1:4570 AVERY LN SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5608
Practice Address - Country:US
Practice Address - Phone:360-464-7935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61582811101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health