Provider Demographics
NPI:1629435045
Name:DIPIETRA, LINDA LOU
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:LOU
Last Name:DIPIETRA
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 1:13217 NE 59TH ST
Mailing Address - Street 2:103
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-5312
Mailing Address - Country:US
Mailing Address - Phone:360-254-2365
Mailing Address - Fax:
Practice Address - Street 1:7415 NE 94TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-3859
Practice Address - Country:US
Practice Address - Phone:360-254-2365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-16
Last Update Date:2016-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
WACG60193148320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health