Provider Demographics
NPI:1619481918
Name:MAYFIELD, EILEEN SUSAN
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:SUSAN
Last Name:MAYFIELD
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 1:5606 W PACIFIC PARK DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-9611
Mailing Address - Country:US
Mailing Address - Phone:509-435-1903
Mailing Address - Fax:
Practice Address - Street 1:701 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-6014
Practice Address - Country:US
Practice Address - Phone:509-838-6092
Practice Address - Fax:509-838-6110
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00000031101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA202064370WAMedicaid