Provider Demographics
NPI:1346631314
Name:MOTLAGH, MITRA MARIUM (MA)
Entity type:Individual
Prefix:MRS
First Name:MITRA
Middle Name:MARIUM
Last Name:MOTLAGH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 SE TECH CENTER PL STE 300
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5509
Mailing Address - Country:US
Mailing Address - Phone:360-844-0282
Mailing Address - Fax:
Practice Address - Street 1:1498 SE TECH CENTER PL STE 300
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5509
Practice Address - Country:US
Practice Address - Phone:360-844-0282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60922499101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health