Provider Demographics
NPI:1942869938
Name:DEMARTINO, DILMA LIZET
Entity Type:Individual
Prefix:
First Name:DILMA
Middle Name:LIZET
Last Name:DEMARTINO
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 1:235 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-2255
Mailing Address - Country:US
Mailing Address - Phone:360-868-2697
Mailing Address - Fax:360-358-8524
Practice Address - Street 1:235 S 3RD ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2255
Practice Address - Country:US
Practice Address - Phone:360-868-2697
Practice Address - Fax:360-358-8524
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60871094101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)