Provider Demographics
NPI:1326539099
Name:GOBLE VAN DIEST, LAURIE J (LICSW)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:J
Last Name:GOBLE VAN DIEST
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:PO BOX 3835
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3835
Mailing Address - Country:US
Mailing Address - Phone:206-548-3114
Mailing Address - Fax:206-762-6355
Practice Address - Street 1:1600 S COLUMBIAN WAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-1565
Practice Address - Country:US
Practice Address - Phone:206-762-2394
Practice Address - Fax:206-762-2421
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000091621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical