Healthcare Provider Details

I. General information

NPI: 1053897017
Provider Name (Legal Business Name): MIU EZRA HART LMHC, SUDPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 SUMMIT AVE
SEATTLE WA
98101-2831
US

IV. Provider business mailing address

1116 SUMMIT AVE
SEATTLE WA
98101-2831
US

V. Phone/Fax

Practice location:
  • Phone: 425-558-0558
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSYC.PY.61607301
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61470827
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: