Provider Demographics
NPI:1699970814
Name:AGING WISDOM INC
Entity type:Organization
Organization Name:AGING WISDOM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DEROSIER
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:206-660-3276
Mailing Address - Street 1:PO BOX 31175
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-1175
Mailing Address - Country:US
Mailing Address - Phone:206-660-3276
Mailing Address - Fax:866-464-8906
Practice Address - Street 1:701 DEXTER AVE N STE 300
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-4342
Practice Address - Country:US
Practice Address - Phone:206-660-3276
Practice Address - Fax:866-464-8906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007998101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty