Provider Demographics
NPI:1013378504
Name:CLARY, MARYLN A
Entity Type:Individual
Prefix:
First Name:MARYLN
Middle Name:A
Last Name:CLARY
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 1:5119 N. KAREN
Mailing Address - Street 2:
Mailing Address - City:OTIS ORCHARDS
Mailing Address - State:WA
Mailing Address - Zip Code:99027
Mailing Address - Country:US
Mailing Address - Phone:509-808-1106
Mailing Address - Fax:
Practice Address - Street 1:5119 N KAREN RD
Practice Address - Street 2:
Practice Address - City:OTIS ORCHARDS
Practice Address - State:WA
Practice Address - Zip Code:99027-9687
Practice Address - Country:US
Practice Address - Phone:509-808-1106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60642152103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst