Provider Demographics
NPI:1013406685
Name:GITAMARA, YUANITA
Entity Type:Individual
Prefix:
First Name:YUANITA
Middle Name:
Last Name:GITAMARA
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 1:815 GLENNING ST
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1318
Mailing Address - Country:US
Mailing Address - Phone:360-201-0698
Mailing Address - Fax:
Practice Address - Street 1:709 FRONT ST
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1819
Practice Address - Country:US
Practice Address - Phone:360-548-7171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61326823101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALH61326823OtherWA STATE LICENSE