Provider Demographics
NPI:1831238351
Name:NELSON, MARTHA E
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:E
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:E
Other - Last Name:WAKENSHAW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:712 N 165TH ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-5302
Mailing Address - Country:US
Mailing Address - Phone:425-771-5166
Mailing Address - Fax:425-670-2807
Practice Address - Street 1:547 DAYTON ST
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3431
Practice Address - Country:US
Practice Address - Phone:425-771-5166
Practice Address - Fax:425-670-2807
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004619101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2858WAOtherREGENCE