Provider Demographics
NPI:1639515117
Name:INDRA, ELLA IDIL (LICSW)
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:IDIL
Last Name:INDRA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8302 26TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-4447
Mailing Address - Country:US
Mailing Address - Phone:206-351-3831
Mailing Address - Fax:
Practice Address - Street 1:720 N 35TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8816
Practice Address - Country:US
Practice Address - Phone:206-351-3831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-11
Last Update Date:2013-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000087081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW00008708OtherWA STATE