Healthcare Provider Details

I. General information

NPI: 1104469048
Provider Name (Legal Business Name): LISA SUZANNE KOTHARI LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 10TH AVE E UNIT B
SEATTLE WA
98102-5708
US

IV. Provider business mailing address

4501 15TH AVE S STE 102
SEATTLE WA
98108-1874
US

V. Phone/Fax

Practice location:
  • Phone: 206-485-2225
  • Fax:
Mailing address:
  • Phone: 206-485-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60995353
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: