Healthcare Provider Details

I. General information

NPI: 1295475499
Provider Name (Legal Business Name): AUDREY MARIE CG, ATR-P
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E FOURTH PLAIN BLVD BLDG 17
VANCOUVER WA
98661-3717
US

IV. Provider business mailing address

PO BOX 1678
VANCOUVER WA
98668-1678
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-8246
  • Fax: 360-397-8448
Mailing address:
  • Phone: 360-397-8246
  • Fax: 360-397-8448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61283254
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number18069
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: