Provider Demographics
NPI:1871143636
Name:FEDIN, ROMAN (CDP)
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:FEDIN
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 E 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99212-3226
Mailing Address - Country:US
Mailing Address - Phone:509-342-5922
Mailing Address - Fax:
Practice Address - Street 1:44 E COZZA DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6514
Practice Address - Country:US
Practice Address - Phone:509-325-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60285814101YA0400X
WAMC61024564101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2077844Medicaid