Provider Demographics
NPI:1093970345
Name:YEARIAN, MARILYN RENEE
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:RENEE
Last Name:YEARIAN
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 1:4313 6TH AVE SE STE C
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1072
Mailing Address - Country:US
Mailing Address - Phone:360-789-8615
Mailing Address - Fax:360-878-9335
Practice Address - Street 1:4313 6TH AVE SE STE C
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1072
Practice Address - Country:US
Practice Address - Phone:360-789-8615
Practice Address - Fax:360-878-9335
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60584958101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2056492Medicaid