Healthcare Provider Details

I. General information

NPI: 1205511185
Provider Name (Legal Business Name): MARICEL CASTORENA MASTRUD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARGO MARICEL MASTRUD

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 05/17/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 NE 41ST ST STE 100
VANCOUVER WA
98662-7935
US

IV. Provider business mailing address

3621 SE SUNRISE DR
CAMAS WA
98607-9419
US

V. Phone/Fax

Practice location:
  • Phone: 360-953-3199
  • Fax:
Mailing address:
  • Phone: 206-999-4504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCA.MC.61604364
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: