Healthcare Provider Details

I. General information

NPI: 1164031480
Provider Name (Legal Business Name): JOHN BRADLEY AMELL PEER COUNSELOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 WALL ST # 100
SEATTLE WA
98121-1431
US

IV. Provider business mailing address

515 3RD AVE
SEATTLE WA
98104-2304
US

V. Phone/Fax

Practice location:
  • Phone: 206-441-3043
  • Fax: 206-441-4155
Mailing address:
  • Phone: 206-464-1570
  • Fax: 206-624-4196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCG60920290
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: