Provider Demographics
NPI:1043713332
Name:LACOURSIERE, MARY ANN (SUDP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:LACOURSIERE
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 AIRPORT WAY S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98134-1618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1412 SW 43RD ST STE 140
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4803
Practice Address - Country:US
Practice Address - Phone:425-264-0750
Practice Address - Fax:425-264-0799
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60793298101YA0400X, 101YA0400X
WACG61396860101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1043713332Medicaid