Provider Demographics
NPI:1720103708
Name:MARYOTT-MOORE, SHELLEY LYNN (LICSW, GMHS, CMHS)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:LYNN
Last Name:MARYOTT-MOORE
Suffix:
Gender:F
Credentials:LICSW, GMHS, CMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LOWER COLUMBIA MENTAL HEALTH/CCGA
Mailing Address - Street 2:921-14TH AVENUE
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-423-2311
Practice Address - Street 1:921-14TH AVE.
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:360-423-2311
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000079541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW00007954OtherLICSW
WA8855729Medicare ID - Type Unspecified