Provider Demographics
NPI:1144616731
Name:ROMAN-ESTRADA, MAGALIE
Entity Type:Individual
Prefix:
First Name:MAGALIE
Middle Name:
Last Name:ROMAN-ESTRADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAGALIE
Other - Middle Name:
Other - Last Name:ESTRADA-MORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:1515 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1846
Mailing Address - Country:US
Mailing Address - Phone:509-488-5256
Mailing Address - Fax:509-488-9939
Practice Address - Street 1:1515 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1846
Practice Address - Country:US
Practice Address - Phone:509-488-5256
Practice Address - Fax:509-488-9939
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WAMC61403044101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMC6143044OtherDEPT OF HEALTH