Provider Demographics
NPI:1316241359
Name:FOSMARK, ANGELA (MA, LMHC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:FOSMARK
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31919 1ST AVE S STE 203
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5229
Mailing Address - Country:US
Mailing Address - Phone:253-221-7123
Mailing Address - Fax:
Practice Address - Street 1:31919 1ST AVE S STE 203
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5229
Practice Address - Country:US
Practice Address - Phone:253-221-7123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60273618101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health