Provider Demographics
NPI:1942965058
Name:KORNYUSHIN-ANDERSON, JULIA (LICSW)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:KORNYUSHIN-ANDERSON
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 1:2905 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-2310
Mailing Address - Country:US
Mailing Address - Phone:360-772-5066
Mailing Address - Fax:
Practice Address - Street 1:2905 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2310
Practice Address - Country:US
Practice Address - Phone:360-772-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6509171R00000X
WA8182171R00000X
WA611513681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171R00000XOther Service ProvidersInterpreter