Provider Demographics
NPI:1720445273
Name:BROWN, MARY (CDP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15314 NE DOLE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:YACOLT
Mailing Address - State:WA
Mailing Address - Zip Code:98675-9521
Mailing Address - Country:US
Mailing Address - Phone:360-260-6300
Mailing Address - Fax:360-686-3966
Practice Address - Street 1:15314 NE DOLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:YACOLT
Practice Address - State:WA
Practice Address - Zip Code:98675-9521
Practice Address - Country:US
Practice Address - Phone:360-260-6300
Practice Address - Fax:360-686-3966
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001919101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)