=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912797028
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. MARY CHELLBERG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2025
-----------------------------------------------------
Last Update Date | 05/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1712 6TH AVE STE 202
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98405-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-473-7586
-----------------------------------------------------
Fax | 253-590-0211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26718 VASHON HWY SW
-----------------------------------------------------
City | VASHON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98070-8319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-847-8055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 61675098
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------