Provider Demographics
NPI:1811291917
Name:DEWALT, MARY B (MS)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:B
Last Name:DEWALT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MRS
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:DEWALT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:4215 E 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-6140
Mailing Address - Country:US
Mailing Address - Phone:509-458-5889
Mailing Address - Fax:509-624-1216
Practice Address - Street 1:906 W 2ND AVE
Practice Address - Street 2:STE. 600
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-4538
Practice Address - Country:US
Practice Address - Phone:509-458-5889
Practice Address - Fax:509-624-1216
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60175550101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health