Provider Demographics
NPI:1902871320
Name:HAMILTON, MARY KATHRYN (PH D)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHRYN
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 RUSTON WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5300
Mailing Address - Country:US
Mailing Address - Phone:253-566-2851
Mailing Address - Fax:253-761-3288
Practice Address - Street 1:4041 RUSTON WAY STE 202
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5300
Practice Address - Country:US
Practice Address - Phone:253-566-2851
Practice Address - Fax:253-761-3288
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPSY 1179103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7078058Medicaid
WAG001002428Medicare ID - Type Unspecified