MEDICARE: DR. MARY ANNE EARLS PH.D.

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
1	103TC0700X	Clinical Psychologist	1597	WA
2	103T00000X	Psychologist	1597	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0170514	OTHER	WA	STATE LABOR & INDUSTRIES

General Provider Information

NPI Number	:	1205827706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ANNE EARLS PH.D.

Provider Business Mailing Address
First Line	:	7683 SE 27TH ST STE 103
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-2804
Country	:	US
Telephone Number	:	206-236-5678
Fax Number	:

Provider Business Practice Location Address
First Line	:	9725 SE 36TH ST
Second Line	:	SUITE 212
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-3841
Country	:	US
Telephone Number	:	206-236-5678
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	07/17/2020

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