Healthcare Provider Details

I. General information

NPI: 1912540485
Provider Name (Legal Business Name): MENGISTEAB EYEHALIK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

415 BOREN AVE APT 230
SEATTLE WA
98104-2409
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-9696
  • Fax:
Mailing address:
  • Phone: 360-304-9780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: