Provider Demographics
NPI:1366103624
Name:CARDELLI, DOMINIC (CTRS)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:CARDELLI
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5521 S LANGSTON RD
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98178-3515
Mailing Address - Country:US
Mailing Address - Phone:248-302-5047
Mailing Address - Fax:
Practice Address - Street 1:414 FRONT ST N
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2914
Practice Address - Country:US
Practice Address - Phone:425-392-6367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program