Provider Demographics
NPI:1376816223
Name:SHANE, MARIA NOVA WINONA (MA, MHP, LMHC)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:NOVA WINONA
Last Name:SHANE
Suffix:
Gender:F
Credentials:MA, MHP, LMHC
Other - Prefix:MRS
Other - First Name:MARIA
Other - Middle Name:NOVA WINONA
Other - Last Name:GUYOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:12106 49TH DR SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-9104
Mailing Address - Country:US
Mailing Address - Phone:206-491-5403
Mailing Address - Fax:
Practice Address - Street 1:611 12TH AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2007
Practice Address - Country:US
Practice Address - Phone:206-834-4029
Practice Address - Fax:206-834-4091
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60153915101YM0800X
WALH60488620101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health