Provider Demographics
NPI:1538775655
Name:HEGSTAD-HULSIZER, MINDY LEE (LICSW ASSOCIATE)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:LEE
Last Name:HEGSTAD-HULSIZER
Suffix:
Gender:F
Credentials:LICSW ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2233
Mailing Address - Country:US
Mailing Address - Phone:360-751-2293
Mailing Address - Fax:
Practice Address - Street 1:42 ELOCHOMAN VALLEY RD
Practice Address - Street 2:
Practice Address - City:CATHLAMET
Practice Address - State:WA
Practice Address - Zip Code:98612-9602
Practice Address - Country:US
Practice Address - Phone:360-795-8630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC610869661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical