Provider Demographics
NPI:1376214247
Name:TAITANO, MINDY LORRAINE
Entity Type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:LORRAINE
Last Name:TAITANO
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MINDY
Other - Middle Name:LORRAINE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:305 PACIFIC AVE S STE C
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-1638
Mailing Address - Country:US
Mailing Address - Phone:360-353-7775
Mailing Address - Fax:
Practice Address - Street 1:305 PACIFIC AVE S STE C
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1638
Practice Address - Country:US
Practice Address - Phone:360-356-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)