Provider Demographics
NPI:1831862598
Name:SUSILO, ANGELA WYNONNA (LMHCA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:WYNONNA
Last Name:SUSILO
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 SHOREWOOD DR APT 145
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-3224
Mailing Address - Country:US
Mailing Address - Phone:331-444-9206
Mailing Address - Fax:
Practice Address - Street 1:3210 SHOREWOOD DR APT 145
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-3224
Practice Address - Country:US
Practice Address - Phone:331-444-9206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61094941101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health