Provider Demographics
NPI:1134631021
Name:MIX, MARIA L (SUDP)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:L
Last Name:MIX
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3096
Mailing Address - Country:US
Mailing Address - Phone:360-423-2806
Mailing Address - Fax:360-423-5128
Practice Address - Street 1:1302 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3096
Practice Address - Country:US
Practice Address - Phone:360-423-2806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60723940101Y00000X
WACO60723940101YA0400X
WA61095293101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2101086Medicaid