Provider Demographics
NPI:1487261186
Name:O'BRIEN, MALLORY ENOLA
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ENOLA
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4908 SW MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98136-1356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 ROMA RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7801
Practice Address - Country:US
Practice Address - Phone:206-669-4604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-26
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61589928101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMHCA.MC.61260603OtherMENTAL HEALTH COUNSELOR LICENSE ID