Healthcare Provider Details

I. General information

NPI: 1366917668
Provider Name (Legal Business Name): WINONA CASANOVA CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2018
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CULLENS ST NW
YELM WA
98597-9417
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 360-400-4860
  • Fax: 360-400-4826
Mailing address:
  • Phone: 206-764-0502
  • Fax: 206-764-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60011979
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: