Healthcare Provider Details

I. General information

NPI: 1003684432
Provider Name (Legal Business Name): FIDDLEHEAD THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21907 64TH AVE W STE 330
MOUNTLAKE TERRACE WA
98043-6238
US

IV. Provider business mailing address

21907 64TH AVE W STE 330
MOUNTLAKE TERRACE WA
98043-6238
US

V. Phone/Fax

Practice location:
  • Phone: 425-399-7063
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: LAURIE GANBERG
Title or Position: OWNER
Credential: MSW, LICSW
Phone: 425-399-7063