Basic Information
| Provider Information | |||||||||
| NPI: | 1417365982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOESCHL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1658 DISCOVERY ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993625010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092407150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9340 NE 76TH ST | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986623721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602534912 | ||||||||
| FaxNumber: | 3602535170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2014 | ||||||||
| LastUpdateDate: | 07/29/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY60049899 | WA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.