Provider Demographics
NPI:1760933600
Name:MEZA, MARA B
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:B
Last Name:MEZA
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 1:19143 15TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-2723
Mailing Address - Country:US
Mailing Address - Phone:253-397-7650
Mailing Address - Fax:
Practice Address - Street 1:4219 SW JUNEAU ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136-1621
Practice Address - Country:US
Practice Address - Phone:206-207-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-15
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60686934101Y00000X
WAMC61396666101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor