Healthcare Provider Details

I. General information

NPI: 1467515528
Provider Name (Legal Business Name): MARY KAY ELLER RC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 E HAWTHORNE AVE
COLVILLE WA
99114-2629
US

IV. Provider business mailing address

686 OLD ARDEN HWY LOT 24
COLVILLE WA
99114-9788
US

V. Phone/Fax

Practice location:
  • Phone: 509-684-4597
  • Fax:
Mailing address:
  • Phone: 509-690-0893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberRC00053048
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: