Provider Demographics
NPI:1609242890
Name:CONCORDIA, MIA (MSW, LSWAIC)
Entity Type:Individual
Prefix:MS
First Name:MIA
Middle Name:
Last Name:CONCORDIA
Suffix:
Gender:F
Credentials:MSW, LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16045 1ST AVE S
Mailing Address - Street 2:FL 1
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98148-1401
Mailing Address - Country:US
Mailing Address - Phone:206-965-4100
Mailing Address - Fax:206-965-4119
Practice Address - Street 1:16045 1ST AVE S FL 1
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98148-1401
Practice Address - Country:US
Practice Address - Phone:206-965-4100
Practice Address - Fax:206-965-4119
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW61076495104100000X, 1041C0700X
WASC 604919441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2165261Medicaid