Provider Demographics
NPI:1538593454
Name:BLOCK, MYRA MARIE
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:MARIE
Last Name:BLOCK
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 1:3322 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4425
Mailing Address - Country:US
Mailing Address - Phone:425-923-6347
Mailing Address - Fax:
Practice Address - Street 1:3322 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4425
Practice Address - Country:US
Practice Address - Phone:425-923-6347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60403754101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor