Provider Demographics
NPI:1255805081
Name:GORDILLO ACOSTA, SANDRA MILENA (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:MILENA
Last Name:GORDILLO ACOSTA
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:MILENA
Other - Last Name:GORDILLO ACOSTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:3084 SW AVALON WAY
Mailing Address - Street 2:UNIT 704 BOX 34
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-4322
Mailing Address - Country:US
Mailing Address - Phone:206-972-5823
Mailing Address - Fax:
Practice Address - Street 1:3808 S ANGELINE ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-1712
Practice Address - Country:US
Practice Address - Phone:206-461-4880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW614750351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical