Provider Demographics
NPI:1376079632
Name:VEASLEY-GAGNER, MARILYN (BA)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:VEASLEY-GAGNER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:F
Other - Last Name:VEASELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:9330 59TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2858
Mailing Address - Country:US
Mailing Address - Phone:253-620-5015
Mailing Address - Fax:
Practice Address - Street 1:9330 59TH AVE SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2858
Practice Address - Country:US
Practice Address - Phone:253-620-5015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60355849101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health