=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306591789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS DEL RIO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2022
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 316 MAIN ST STE A1
-----------------------------------------------------
City | EDMONDS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98020-3197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-753-0102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4115 ROSEDALE ST UNIT 29
-----------------------------------------------------
City | GIG HARBOR
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98335-1877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-753-0102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | S.2309125
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SC61440337
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------