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NPI Code Detail

MEDICARE: MARIA L MIX SUDP

MEDICARE: MARIA L MIX SUDP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101Y00000XCounselor60723940WA
2101YA0400XAddiction (Substance Use Disorder) CounselorCO60723940WA
3101YA0400XAddiction (Substance Use Disorder) Counselor61095293WA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1134631021
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARIA L MIX SUDP
Provider Business Mailing Address
First Line : 1302 COMMERCE AVE
Second Line :
City : LONGVIEW
State : WA
Zip : 98632-3096
Country : US
Telephone Number : 360-423-2806
Fax Number : 360-423-5128
Provider Business Practice Location Address
First Line : 1302 COMMERCE AVE
Second Line :
City : LONGVIEW
State : WA
Zip : 98632-3096
Country : US
Telephone Number : 360-423-2806
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/31/2017
Last Update Date : 04/23/2024

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Directions to “ MARIA L MIX SUDP” Practice Location

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