Healthcare Provider Details

I. General information

NPI: 1255767562
Provider Name (Legal Business Name): LORA IVANOVA KIM LMHC, MHP, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 SUMMIT AVE E STE 25
SEATTLE WA
98102-5619
US

IV. Provider business mailing address

P.O. BOX 9572
SEATTLE WA
98109
US

V. Phone/Fax

Practice location:
  • Phone: 206-536-7503
  • Fax:
Mailing address:
  • Phone: 888-232-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: