MEDICARE: LOGICAL MENTAL HEALTH SERVICES

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1639882913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOGICAL MENTAL HEALTH SERVICES

Provider Business Mailing Address
First Line	:	4301 S PINE ST STE 30-12
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98409-9123
Country	:	US
Telephone Number	:	206-765-0592
Fax Number	:

Provider Business Practice Location Address
First Line	:	4301 S PINE ST STE 30-12
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98409-9123
Country	:	US
Telephone Number	:	206-765-0592
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	FADUMO I OMAR
Credential	:	ARNP-C
Telephone Number	:	206-250-7034

Provider Enumeration Date	:	01/02/2023
Last Update Date	:	08/11/2023

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