Healthcare Provider Details

I. General information

NPI: 1134631021
Provider Name (Legal Business Name): MARIA L MIX SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 COMMERCE AVE
LONGVIEW WA
98632-3096
US

IV. Provider business mailing address

1302 COMMERCE AVE
LONGVIEW WA
98632-3096
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-2806
  • Fax:
Mailing address:
  • Phone: 360-423-2806
  • Fax: 360-423-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number60723940
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60723940
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number61095293
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: