Provider Demographics
NPI:1225515729
Name:ZURITA VERGARA, MARTHA ISABEL
Entity Type:Individual
Prefix:MISS
First Name:MARTHA
Middle Name:ISABEL
Last Name:ZURITA VERGARA
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 1:210 SIMPSON PKWY APT 832
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-5017
Mailing Address - Country:US
Mailing Address - Phone:509-318-9686
Mailing Address - Fax:
Practice Address - Street 1:1521 E ILLINOIS AVE STE 107
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-5147
Practice Address - Country:US
Practice Address - Phone:208-217-5529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA18-58599106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician