Healthcare Provider Details

I. General information

NPI: 1326539099
Provider Name (Legal Business Name): LAURA J. GOBLE VAN DIEST LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8609 EVERGREEN WAY
EVERETT WA
98208-2619
US

IV. Provider business mailing address

8609 EVERGREEN WAY
EVERETT WA
98208-2619
US

V. Phone/Fax

Practice location:
  • Phone: 425-789-3700
  • Fax:
Mailing address:
  • Phone: 425-789-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLW00009162
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: