Provider Demographics
NPI:1770344517
Name:COGOLLOS, CLARA (LSWAIC)
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:COGOLLOS
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:CLARA
Other - Middle Name:CRISTINA
Other - Last Name:COGOLLOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSWAIC
Mailing Address - Street 1:3735 115TH AVE NE # APRI207
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-7950
Mailing Address - Country:US
Mailing Address - Phone:201-647-6590
Mailing Address - Fax:
Practice Address - Street 1:900 PACIFIC AVE STE 100
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4188
Practice Address - Country:US
Practice Address - Phone:425-258-7096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC611802311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical