Provider Demographics
NPI:1528572633
Name:EVENMOE, MARTHA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:EVENMOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:CHARLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:921 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:615 8TH ST
Practice Address - Street 2:
Practice Address - City:HOQUIAM
Practice Address - State:WA
Practice Address - Zip Code:98550-3522
Practice Address - Country:US
Practice Address - Phone:360-532-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60796207101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health