Provider Demographics
NPI:1538585781
Name:ANJILLIA DIBAUM
Entity type:Organization
Organization Name:ANJILLIA DIBAUM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:BAUMGARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-972-2999
Mailing Address - Street 1:5340 BALLARD AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4060
Mailing Address - Country:US
Mailing Address - Phone:206-972-2999
Mailing Address - Fax:
Practice Address - Street 1:5340 BALLARD AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4060
Practice Address - Country:US
Practice Address - Phone:206-972-2999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TP2701X
WA133N00000X, 171100000X, 175F00000X
MA225700000X
WA602902322261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty