Basic Information
| Provider Information | |||||||||
| NPI: | 1972076123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHINNELL-MATEEN | ||||||||
| FirstName: | AJA-AMINA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MA, LMHC, MHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1210 SW 136TH ST | ||||||||
| Address2: | |||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981661214 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 26401 PACIFIC HWY S | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981989247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538337444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2019 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2123402 | 05 | WA | MEDICAID |