Provider Demographics
NPI:1669071510
Name:MONGRAIN, TERRY (HIS)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:
Last Name:MONGRAIN
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 VALLEY MALL PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-4838
Mailing Address - Country:US
Mailing Address - Phone:509-888-3277
Mailing Address - Fax:509-888-4327
Practice Address - Street 1:612 VALLEY MALL PKWY
Practice Address - Street 2:
Practice Address - City:EAST WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802-4838
Practice Address - Country:US
Practice Address - Phone:509-888-3277
Practice Address - Fax:509-888-4327
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA61034979237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAHA61034979OtherHEARING AID SPECIALIST LICENSE