Provider Demographics
NPI:1356821078
Name:GOLDNER, HALLE ZIRA (SUDP)
Entity Type:Individual
Prefix:MS
First Name:HALLE
Middle Name:ZIRA
Last Name:GOLDNER
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 PETERSON RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-2606
Mailing Address - Country:US
Mailing Address - Phone:360-757-0131
Mailing Address - Fax:
Practice Address - Street 1:614 PETERSON RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-2606
Practice Address - Country:US
Practice Address - Phone:360-757-0131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60838734101YA0400X
WACP61128194101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1356821078Medicaid