Healthcare Provider Details

I. General information

NPI: 1497148878
Provider Name (Legal Business Name): JOHN DAVID WELBORN MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 SW 136TH ST
BURIEN WA
98166-1214
US

IV. Provider business mailing address

1210 SW 136TH ST
BURIEN WA
98166-1214
US

V. Phone/Fax

Practice location:
  • Phone: 206-257-6600
  • Fax: 206-257-6825
Mailing address:
  • Phone: 206-257-6600
  • Fax: 206-257-6825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC 60435601
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: