Provider Demographics
NPI:1033313184
Name:HACKSTAFF, LYNN (LICSW)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:HACKSTAFF
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 SE EVERETT MALL WAY UNIT L
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-2809
Mailing Address - Country:US
Mailing Address - Phone:310-619-5085
Mailing Address - Fax:
Practice Address - Street 1:6505 216TH ST SW STE 100
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2089
Practice Address - Country:US
Practice Address - Phone:425-640-7009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS11925363A00000X
WALW609953881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60995388OtherINDEPENDENT CLINICAL SOCIAL WORKER LICENSE