Healthcare Provider Details

I. General information

NPI: 1801206602
Provider Name (Legal Business Name): MARIAH LELISE HASKEW-GALLANT CPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7803 NE FOURTH PLN RD
VANCOUVER WA
98662-7246
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-9211
  • Fax: 360-260-4900
Mailing address:
  • Phone: 206-764-0502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60461124
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: