Healthcare Provider Details

I. General information

NPI: 1992814925
Provider Name (Legal Business Name): SUSAN RUBY MA, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22602 14TH PL W
BOTHELL WA
98021-9438
US

IV. Provider business mailing address

10500 BEARDSLEE BLVD UNIT 1881
BOTHELL WA
98041-0347
US

V. Phone/Fax

Practice location:
  • Phone: 206-915-9876
  • Fax: 425-286-6116
Mailing address:
  • Phone: 206-915-9876
  • Fax: 425-286-6116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLH00011015
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: