Provider Demographics
NPI:1467764522
Name:WALL, MARY ALICE (CDP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALICE
Last Name:WALL
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:COMPASS HEALTH
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98213
Mailing Address - Country:US
Mailing Address - Phone:425-349-6200
Mailing Address - Fax:
Practice Address - Street 1:201 LILA LANE
Practice Address - Street 2:COMPASS HEALTH SKAGIT COUNTY CRISIS CENTER
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223
Practice Address - Country:US
Practice Address - Phone:360-419-7509
Practice Address - Fax:360-757-1687
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001075101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)