Healthcare Provider Details

I. General information

NPI: 1669522165
Provider Name (Legal Business Name): KIMBERLY JOANN THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2719 E MADISON ST SUITE 200
SEATTLE WA
98112-4752
US

IV. Provider business mailing address

10215 LAKE CITY WAY NE
SEATTLE WA
98125-7757
US

V. Phone/Fax

Practice location:
  • Phone: 206-302-2344
  • Fax:
Mailing address:
  • Phone: 206-417-9904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberRC00053181
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCG60171011
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG60171011
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: