Provider Demographics
NPI:1023481504
Name:MOULTRY, MARSHAN M
Entity type:Individual
Prefix:
First Name:MARSHAN
Middle Name:M
Last Name:MOULTRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 VIRGINIA ST SUITE 210
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101
Mailing Address - Country:US
Mailing Address - Phone:206-470-3856
Mailing Address - Fax:
Practice Address - Street 1:1100 VIRGINIA ST SUITE 210
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101
Practice Address - Country:US
Practice Address - Phone:206-470-3856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60539426101YA0400X
WAMG60582705101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)