Provider Demographics
NPI:1245687466
Name:NELSEN-SOZA, DARYN (LSWIAC)
Entity type:Individual
Prefix:
First Name:DARYN
Middle Name:
Last Name:NELSEN-SOZA
Suffix:
Gender:F
Credentials:LSWIAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16812 SE 1ST ST UNIT 32
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-8503
Mailing Address - Country:US
Mailing Address - Phone:360-798-8604
Mailing Address - Fax:
Practice Address - Street 1:16812 SE 1ST ST UNIT 32
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-8503
Practice Address - Country:US
Practice Address - Phone:360-798-8604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA4239104100000X
WASC 605479311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker