Healthcare Provider Details

I. General information

NPI: 1366103624
Provider Name (Legal Business Name): DOMINIC CARDELLI CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/07/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 FRONT ST N
ISSAQUAH WA
98027-2914
US

IV. Provider business mailing address

5521 S LANGSTON RD
SEATTLE WA
98178-3515
US

V. Phone/Fax

Practice location:
  • Phone: 425-392-6367
  • Fax:
Mailing address:
  • Phone: 248-302-5047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: