Provider Demographics
NPI:1891036315
Name:SHOCKLEY, MARY E (MED LMHC MHP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:SHOCKLEY
Suffix:
Gender:F
Credentials:MED LMHC MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12533 REINER RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-9553
Mailing Address - Country:US
Mailing Address - Phone:425-770-1117
Mailing Address - Fax:
Practice Address - Street 1:12533 REINER RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272
Practice Address - Country:US
Practice Address - Phone:425-770-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2020-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60855866101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2111780Medicaid