Healthcare Provider Details

I. General information

NPI: 1033863592
Provider Name (Legal Business Name): LIMINAL TERRESTRIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 E MADISON ST STE 112
SEATTLE WA
98112-4214
US

IV. Provider business mailing address

2910 E MADISON ST STE 112
SEATTLE WA
98112-4214
US

V. Phone/Fax

Practice location:
  • Phone: 206-717-4433
  • Fax:
Mailing address:
  • Phone: 206-717-4433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE KOSAK
Title or Position: EXECUTIVE DIRECTOR
Credential: LMHC, ATR
Phone: 206-717-4433