Basic Information
| Provider Information | |||||||||
| NPI: | 1033404058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUY | ||||||||
| FirstName: | CONSTANCE | ||||||||
| MiddleName: | RAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1106 COLUMBIA AVE STE 151 | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982704347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606530374 | ||||||||
| FaxNumber: | 3605681654 | ||||||||
| Practice Location | |||||||||
| Address1: | 1106 COLUMBIA AVE STE 151 | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982704347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606530374 | ||||||||
| FaxNumber: | 3605681654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2011 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2047491 | 05 | WA | MEDICAID | 20150810721237 | 05 | WA | MEDICAID |