Healthcare Provider Details

I. General information

NPI: 1821681297
Provider Name (Legal Business Name): MARIAH DEE SHANNON GOLDSTON CG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIAH DEE SHANNON GORDON CG

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 E FOURTH PLAIN BLVD
VANCOUVER WA
98661-3965
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 360-831-0904
  • Fax: 360-433-9917
Mailing address:
  • Phone: 253-681-6603
  • Fax: 206-764-8005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: