Provider Demographics
NPI:1700051877
Name:BRAUTIGAM MILLS, MARY JEAN (NCC, LMHC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:BRAUTIGAM MILLS
Suffix:
Gender:F
Credentials:NCC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 N 60TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-4861
Mailing Address - Country:US
Mailing Address - Phone:425-985-3640
Mailing Address - Fax:
Practice Address - Street 1:470 FRONT ST N
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2914
Practice Address - Country:US
Practice Address - Phone:425-985-3640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALMHC00006100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALMHC00006100OtherWASHINGTON STATE LMHC