Provider Demographics
NPI:1619266830
Name:LAGROTTA, DALIS L
Entity Type:Individual
Prefix:
First Name:DALIS
Middle Name:L
Last Name:LAGROTTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 W BELL ST STE D
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-2916
Mailing Address - Country:US
Mailing Address - Phone:360-797-1429
Mailing Address - Fax:360-477-4939
Practice Address - Street 1:435 W BELL ST STE D
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-2916
Practice Address - Country:US
Practice Address - Phone:360-797-1429
Practice Address - Fax:360-477-4939
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00011385101YM0800X
WAMC60205849101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health