MEDICARE: FAMILY RESTORATION & EMPOWERMENT ENTERPRISES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LH60806253	WA

General Provider Information

NPI Number	:	1174036099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY RESTORATION & EMPOWERMENT ENTERPRISES

Provider Business Mailing Address
First Line	:	2615 19TH STREET PL SW
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98373-3953
Country	:	US
Telephone Number	:	253-365-3964
Fax Number	:

Provider Business Practice Location Address
First Line	:	1554 S GRANT AVE
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98405-3250
Country	:	US
Telephone Number	:	253-365-3964
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. MONIQUE RENEE JORDAN
Credential	:	LMHC
Telephone Number	:	253-365-3964

Provider Enumeration Date	:	11/14/2017
Last Update Date	:	11/14/2017

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Directions to “FAMILY RESTORATION & EMPOWERMENT ENTERPRISES ” Practice Location

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