Basic Information
| Provider Information | |||||||||
| NPI: | 1033313184 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HACKSTAFF | ||||||||
| FirstName: | LYNN | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 SE EVERETT MALL WAY UNIT L | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982082809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106195085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6505 216TH ST SW STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOUNTLAKE TERRACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980432089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256407009 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | LCS11925 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 1041C0700X | LW60995388 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 60995388 | 01 | WA | INDEPENDENT CLINICAL SOCIAL WORKER LICENSE | OTHER |