Healthcare Provider Details

I. General information

NPI: 1538585781
Provider Name (Legal Business Name): ANJILLIA DIBAUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5340 BALLARD AVE NW
SEATTLE WA
98107-4060
US

IV. Provider business mailing address

5340 BALLARD AVE NW
SEATTLE WA
98107-4060
US

V. Phone/Fax

Practice location:
  • Phone: 206-972-2999
  • Fax:
Mailing address:
  • Phone: 206-972-2999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number602902322
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateMA

VIII. Authorized Official

Name: MISS ANGELA MAE BAUMGARDNER
Title or Position: OWNER
Credential:
Phone: 206-972-2999