Provider Demographics
NPI:1447643432
Name:DE VINE, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:DE VINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98666-1337
Mailing Address - Country:US
Mailing Address - Phone:360-253-6019
Mailing Address - Fax:
Practice Address - Street 1:7415 NE 94TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-3859
Practice Address - Country:US
Practice Address - Phone:360-253-6019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-15
Last Update Date:2015-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60284828101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health