Basic Information
| Provider Information | |||||||||
| NPI: | 1992949184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBER | ||||||||
| FirstName: | MARTY | ||||||||
| MiddleName: | EDMUND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 SOUTH 2ND STREET | ||||||||
| Address2: | |||||||||
| City: | MT. VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604193500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 S 2ND ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982734209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604193500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2009 | ||||||||
| LastUpdateDate: | 05/01/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 101Y00000X | WA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.