Healthcare Provider Details

I. General information

NPI: 1982976197
Provider Name (Legal Business Name): ADELINA GEORGIEVA DANA M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 WOODLAND SQUARE LOOP SE STE 401
LACEY WA
98503-1070
US

IV. Provider business mailing address

612 WOODLAND SQUARE LOOP SE STE 401
LACEY WA
98503-1070
US

V. Phone/Fax

Practice location:
  • Phone: 360-401-9006
  • Fax:
Mailing address:
  • Phone: 360-401-9006
  • Fax: 360-489-1435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60270005
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLH60446421
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: