Provider Demographics
NPI:1689496309
Name:VISCO, MARIAH E (AAC CG61589288)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:E
Last Name:VISCO
Suffix:
Gender:F
Credentials:AAC CG61589288
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CANYON PKWY UNIT B1
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-1258
Mailing Address - Country:US
Mailing Address - Phone:978-621-0163
Mailing Address - Fax:
Practice Address - Street 1:120 S 3RD ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-2875
Practice Address - Country:US
Practice Address - Phone:509-248-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61589288101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-0755984Medicaid