Provider Demographics
NPI:1962555656
Name:ROSS, MARIAM (LW60276157)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:LW60276157
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3603
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3603
Mailing Address - Country:US
Mailing Address - Phone:360-341-5252
Mailing Address - Fax:360-341-8727
Practice Address - Street 1:11245 STATE ROUTE 525
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:WA
Practice Address - Zip Code:98236-8638
Practice Address - Country:US
Practice Address - Phone:360-341-5252
Practice Address - Fax:360-341-8727
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW602761571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical