Provider Demographics
NPI:1093005043
Name:BAILEY, LINDA LEE (MDIV)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:LEE
Last Name:BAILEY
Suffix:
Gender:F
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 956
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-0956
Mailing Address - Country:US
Mailing Address - Phone:360-827-2065
Mailing Address - Fax:360-669-0524
Practice Address - Street 1:2451 NE KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2436
Practice Address - Country:US
Practice Address - Phone:360-827-2065
Practice Address - Fax:360-669-0524
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF 60342675106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2043560Medicaid