Basic Information
Provider Information | |||||||||
NPI: | 1609242890 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONCORDIA | ||||||||
FirstName: | MIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW, LSWAIC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16045 1ST AVE S | ||||||||
Address2: | FL 1 | ||||||||
City: | BURIEN | ||||||||
State: | WA | ||||||||
PostalCode: | 981481401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2069654100 | ||||||||
FaxNumber: | 2069654119 | ||||||||
Practice Location | |||||||||
Address1: | 16045 1ST AVE S FL 1 | ||||||||
Address2: |   | ||||||||
City: | BURIEN | ||||||||
State: | WA | ||||||||
PostalCode: | 981481401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2069654100 | ||||||||
FaxNumber: | 2069654119 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2015 | ||||||||
LastUpdateDate: | 10/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LW61076495 | WA | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | SC 60491944 | WA | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LW61076495 | WA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 2165261 | 05 | WA |   | MEDICAID |