Healthcare Provider Details

I. General information

NPI: 1912929258
Provider Name (Legal Business Name): DARREN MICHAEL NEALIS LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18313 PAULSON ST SW STE A
ROCHESTER WA
98579-9262
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-827-8400
  • Fax: 360-273-7301
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60065730
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: