Provider Demographics
NPI:1689142085
Name:ZSIDIEWICZ, AUNASTASIA FANTASIA MARIE (LICSWA, AAC, CADC I)
Entity Type:Individual
Prefix:
First Name:AUNASTASIA
Middle Name:FANTASIA MARIE
Last Name:ZSIDIEWICZ
Suffix:
Gender:F
Credentials:LICSWA, AAC, CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 N HIGHWAY 101 STE 204
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:OR
Mailing Address - Zip Code:97146-9371
Mailing Address - Country:US
Mailing Address - Phone:503-325-0241
Mailing Address - Fax:503-861-2043
Practice Address - Street 1:65 N HIGHWAY 101 STE 204
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:OR
Practice Address - Zip Code:97146-9371
Practice Address - Country:US
Practice Address - Phone:503-325-0241
Practice Address - Fax:503-861-2043
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WASC610988201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)