Basic Information
| Provider Information | |||||||||
| NPI: | 1821681297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | MARIAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34703 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536816603 | ||||||||
| FaxNumber: | 2067648005 | ||||||||
| Practice Location | |||||||||
| Address1: | 2504 E FOURTH PLAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986613965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608310904 | ||||||||
| FaxNumber: | 3604339917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2021 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106S00000X | N | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.