Basic Information
| Provider Information | |||||||||
| NPI: | 1326523325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIELEMAN | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9800 4TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981152158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063021200 | ||||||||
| FaxNumber: | 2063021283 | ||||||||
| Practice Location | |||||||||
| Address1: | 9800 4TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981152152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063021200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2018 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149018068 | IL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LW60874880 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LW60874880 | 01 | WA | LICSW | OTHER | 149018068 | 01 | IL | LICENSED CLINICAL SOCIAL WORKER | OTHER |