Provider Demographics
NPI:1093059628
Name:EDIDIN, MIA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:EDIDIN
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 1:2319 N 45TH ST
Mailing Address - Street 2:#303
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-6982
Mailing Address - Country:US
Mailing Address - Phone:206-659-7773
Mailing Address - Fax:
Practice Address - Street 1:2319 N 45TH ST
Practice Address - Street 2:#303
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6982
Practice Address - Country:US
Practice Address - Phone:206-659-7773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
WALW601611911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker