Provider Demographics
NPI:1992078653
Name:ANTUSH, MARYLYNN (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:MARYLYNN
Middle Name:
Last Name:ANTUSH
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 N 202ND PL
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-3335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14 E CASINO RD
Practice Address - Street 2:BUILDING D
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-2628
Practice Address - Country:US
Practice Address - Phone:425-374-4279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000056981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical