Provider Demographics
NPI:1922597152
Name:MCILWAIN, MARIANA (AUD)
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:MCILWAIN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 LILLY RD NE STE 202
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-7400
Mailing Address - Country:US
Mailing Address - Phone:360-357-6314
Mailing Address - Fax:360-705-3745
Practice Address - Street 1:128 LILLY RD NE STE 202
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-7400
Practice Address - Country:US
Practice Address - Phone:360-357-6314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD60863106231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-1829653OtherTAX ID