Provider Demographics
NPI:1033404058
Name:GUY, CONSTANCE RAE
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:RAE
Last Name:GUY
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 1:1106 COLUMBIA AVE STE 151
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4347
Mailing Address - Country:US
Mailing Address - Phone:360-653-0374
Mailing Address - Fax:360-568-1654
Practice Address - Street 1:1106 COLUMBIA AVE STE 151
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4347
Practice Address - Country:US
Practice Address - Phone:360-653-0374
Practice Address - Fax:360-568-1654
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2047491Medicaid
WA20150810721237Medicaid