Provider Demographics
NPI:1720416647
Name:GEBAUER, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:GEBAUER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:PFRIEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4526 FEDERAL AVE BLDG 1
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2132
Mailing Address - Country:US
Mailing Address - Phone:425-349-7444
Mailing Address - Fax:
Practice Address - Street 1:4526 FEDERAL AVE BLDG 1
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2132
Practice Address - Country:US
Practice Address - Phone:425-349-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-31
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60326483101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health