Provider Demographics
NPI:1962708610
Name:EZELLE, SHERESE DANIELLE
Entity type:Individual
Prefix:MS
First Name:SHERESE
Middle Name:DANIELLE
Last Name:EZELLE
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 1:702 37TH ST SE APT B
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-8062
Mailing Address - Country:US
Mailing Address - Phone:206-331-9746
Mailing Address - Fax:
Practice Address - Street 1:702 37TH ST SE APT B
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-8062
Practice Address - Country:US
Practice Address - Phone:971-770-0724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2023-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010389101YM0800X
WALH60664607101YM0800X, 101YM0800X
COLPC.0017039101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health