Healthcare Provider Details

I. General information

NPI: 1629435045
Provider Name (Legal Business Name): LINDA LOU DIPIETRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2016
Last Update Date: 01/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7415 NE 94TH AVE
VANCOUVER WA
98662-3859
US

IV. Provider business mailing address

13217 NE 59TH ST 103
VANCOUVER WA
98682-5312
US

V. Phone/Fax

Practice location:
  • Phone: 360-254-2365
  • Fax:
Mailing address:
  • Phone: 360-254-2365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberCG60193148
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: