Angela Wynonna Susilo, LMHCA

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

MC61094941 Issued in WA

Practice address

3210 Shorewood Dr Apt 145
Mercer Island, WA 98040-3224

Phone

(331) 444-9206

NPI assigned

Jul 28, 2021

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Mindful Therapy Group PC

  dba Mindful Therapy Group

  • Clinical Social Worker
  • Mountlake Terrace, WA
  • NPI 1316238678

  Mental Health

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1627430400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1628899200000",
    "number": "1831862598",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3210 SHOREWOOD DR APT 145",
            "city": "MERCER ISLAND",
            "state": "WA",
            "postal_code": "980403224",
            "telephone_number": "331-444-9206"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3210 SHOREWOOD DR APT 145",
            "city": "MERCER ISLAND",
            "state": "WA",
            "postal_code": "980403224",
            "telephone_number": "331-444-9206"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "123 NW 36th St Ste 210",
            "address_purpose": "LOCATION",
            "city": "Seattle",
            "state": "WA",
            "postal_code": "981074959",
            "country_code": "US",
            "telephone_number": "206-402-5767",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "SUSILO",
        "first_name": "ANGELA",
        "middle_name": "WYNONNA",
        "credential": "LMHCA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2021-07-28",
        "last_updated": "2021-08-14",
        "certification_date": "2021-08-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "WA",
            "license": "MC61094941",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jennifer Strelow, DMD
• Alexandra Cecil Styhl, MD
• Claire Sullivan, PT, DPT
• Tian Sun
• Sunbridge Healthcare LLC (Mercer Island Center)
• Katie Beth Swanson, PT
• Maureen L Swift, D.D.S. M.S.D.
• Paul B Sytman, MD
• Ryan Tam, DDS
• Jacklyn Halibas Tan, LMHCA

• Mental Health Counselor in Mercer Island, WA
• Providers in Mercer Island, WA by specialty
• Mental Health Counselor in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.