Provider Demographics
NPI:1720503584
Name:LOLLIS, DARNELL
Entity Type:Individual
Prefix:MR
First Name:DARNELL
Middle Name:
Last Name:LOLLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S 2ND ST # 2
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-4209
Mailing Address - Country:US
Mailing Address - Phone:425-319-1242
Mailing Address - Fax:
Practice Address - Street 1:1100 S 2ND ST # 2
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4209
Practice Address - Country:US
Practice Address - Phone:425-349-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-13
Last Update Date:2017-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC607398791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical