Provider Demographics
NPI:1730491424
Name:DILTZ, STEPHANIE MARIE (CDP, LICSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:DILTZ
Suffix:
Gender:F
Credentials:CDP, LICSW
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:M
Other - Last Name:TRUMBULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:908 GEORGIANA ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-3912
Mailing Address - Country:US
Mailing Address - Phone:360-504-3731
Mailing Address - Fax:360-504-3984
Practice Address - Street 1:908 GEORGIANA ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3912
Practice Address - Country:US
Practice Address - Phone:360-504-3731
Practice Address - Fax:360-504-3984
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60253597101YA0400X, 101YA0400X
WALW609961641041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical