Provider Demographics
NPI:1821151739
Name:STERN, MINDY (LSW)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:STERN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-0172
Mailing Address - Country:US
Mailing Address - Phone:206-605-6095
Mailing Address - Fax:
Practice Address - Street 1:4047 96TH AVE SE
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-4231
Practice Address - Country:US
Practice Address - Phone:206-605-6095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00004730104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
S70434Medicare UPIN
WAAB12679Medicare ID - Type Unspecified