Provider Demographics
NPI:1649054776
Name:MAMON, MERESSA
Entity type:Individual
Prefix:
First Name:MERESSA
Middle Name:
Last Name:MAMON
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 1:4301 S PINE ST STE 92
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7259
Mailing Address - Country:US
Mailing Address - Phone:253-507-5334
Mailing Address - Fax:
Practice Address - Street 1:4301 S PINE ST STE 92
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7259
Practice Address - Country:US
Practice Address - Phone:253-507-5334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO06138911101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)