Provider Demographics
NPI:1720758535
Name:PERSONIUS, DEEANNA (LW61596199)
Entity type:Individual
Prefix:
First Name:DEEANNA
Middle Name:
Last Name:PERSONIUS
Suffix:
Gender:F
Credentials:LW61596199
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15455 65TH AVE S
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2534
Practice Address - Country:US
Practice Address - Phone:206-721-5170
Practice Address - Fax:360-575-1950
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW61596199104100000X
WASC61188432101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker