Healthcare Provider Details

I. General information

NPI: 1790335974
Provider Name (Legal Business Name): TARA BUBRISKI LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 1ST AVE STE 531
SEATTLE WA
98104-2229
US

IV. Provider business mailing address

600 1ST AVE STE 531
SEATTLE WA
98104-2229
US

V. Phone/Fax

Practice location:
  • Phone: 802-236-7016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60985495
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: