Provider Demographics
NPI:1578193066
Name:WOOTEN, MYRA JOLENE
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:JOLENE
Last Name:WOOTEN
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 1:1000 AUBURN WAY S
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-6132
Mailing Address - Country:US
Mailing Address - Phone:253-939-2202
Mailing Address - Fax:
Practice Address - Street 1:1000 AUBURN WAY S
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-6132
Practice Address - Country:US
Practice Address - Phone:253-939-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00000Other00000