Healthcare Provider Details

I. General information

NPI: 1255365201
Provider Name (Legal Business Name): RIVER MARY MALCOLM LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 DISCOVERY WAY
EASTSOUND WA
98245-2212
US

IV. Provider business mailing address

11 DISCOVERY WAY
EASTSOUND WA
98245-2212
US

V. Phone/Fax

Practice location:
  • Phone: 360-376-4548
  • Fax:
Mailing address:
  • Phone: 360-376-4548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLF0001312
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 25020
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: