Healthcare Provider Details

I. General information

NPI: 1699121616
Provider Name (Legal Business Name): TARA SEDOV LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 04/02/2023
Certification Date: 04/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9757 NE JUANITA DR STE 214
KIRKLAND WA
98034-4291
US

IV. Provider business mailing address

9757 NE JUANITA DR STE 214
KIRKLAND WA
98034-4291
US

V. Phone/Fax

Practice location:
  • Phone: 425-943-9360
  • Fax: 425-968-1259
Mailing address:
  • Phone: 425-943-9360
  • Fax: 206-764-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC60820011
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61073138
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: