Provider Demographics
NPI:1831894443
Name:IRWIN, BENJAWAN MOOLKEO (MC61356988)
Entity type:Individual
Prefix:
First Name:BENJAWAN
Middle Name:MOOLKEO
Last Name:IRWIN
Suffix:
Gender:F
Credentials:MC61356988
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 E SPANGLE WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:SPANGLE
Mailing Address - State:WA
Mailing Address - Zip Code:99031-9703
Mailing Address - Country:US
Mailing Address - Phone:423-240-5654
Mailing Address - Fax:
Practice Address - Street 1:3025 E SPANGLE WAVERLY RD # HOUSE19
Practice Address - Street 2:
Practice Address - City:SPANGLE
Practice Address - State:WA
Practice Address - Zip Code:99031-9703
Practice Address - Country:US
Practice Address - Phone:423-240-5654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61356988101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health