Healthcare Provider Details

I. General information

NPI: 1215330519
Provider Name (Legal Business Name): SAMUEL MCQUEEN BA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2014
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 W MEEKER ST SUITE 201
KENT WA
98032-4323
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 206-764-8019
  • Fax: 253-480-2937
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60547496
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: