Healthcare Provider Details

I. General information

NPI: 1730775792
Provider Name (Legal Business Name): MARIA DE LA LUZ PARDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 SUMNER AVE
ABERDEEN WA
98520-4600
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 360-538-1461
  • Fax: 360-537-4202
Mailing address:
  • Phone: 206-764-0502
  • Fax: 206-764-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG60756201
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: