MEDICARE: HEAVENSFIELD GROUP, LLC

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	LH00003472	WA
2	1041C0700X	Clinical Social Worker	SC60106047	WA

General Provider Information

NPI Number	:	1194092130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENSFIELD GROUP, LLC

Provider Business Mailing Address
First Line	:	1001 290TH AVE SE
Second Line	:
City	:	FALL CITY
State	:	WA
Zip	:	98024-7403
Country	:	US
Telephone Number	:	425-222-3706
Fax Number	:	888-788-3419

Provider Business Practice Location Address
First Line	:	1001 290TH AVE SE
Second Line	:
City	:	FALL CITY
State	:	WA
Zip	:	98024-7403
Country	:	US
Telephone Number	:	425-222-3706
Fax Number	:	888-788-3419

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	COSETTE D RAE
Credential	:	MSW, LSWAIC
Telephone Number	:	425-417-0406

Provider Enumeration Date	:	11/18/2011
Last Update Date	:	11/18/2011

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