Healthcare Provider Details

I. General information

NPI: 1295690832
Provider Name (Legal Business Name): MASTEWAL MENGESHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 MADISON ST
EVERETT WA
98203-4543
US

IV. Provider business mailing address

811 MADISON ST
EVERETT WA
98203-4543
US

V. Phone/Fax

Practice location:
  • Phone: 425-212-4200
  • Fax:
Mailing address:
  • Phone: 425-212-4200
  • Fax: 425-212-4200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number61643574
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: