Provider Demographics
NPI:1790140812
Name:MOUNT, MARLA
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:MOUNT
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 1:6322 201ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9670
Mailing Address - Country:US
Mailing Address - Phone:360-970-8778
Mailing Address - Fax:866-270-5866
Practice Address - Street 1:60 NW BOISFORT ST.
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532
Practice Address - Country:US
Practice Address - Phone:360-970-8778
Practice Address - Fax:866-270-5866
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60611725106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2050195Medicaid
WA1790140812OtherNPI