Healthcare Provider Details

I. General information

NPI: 1265077846
Provider Name (Legal Business Name): BUENA VIDA COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 07/12/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2146 W RAILROAD AVE STE A
SHELTON WA
98584-7126
US

IV. Provider business mailing address

PO BOX 541
SHELTON WA
98584-0541
US

V. Phone/Fax

Practice location:
  • Phone: 360-358-2085
  • Fax: 360-485-4964
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA MARIE WELLMAN
Title or Position: OWNER/MANAGING MEMBER
Credential: LMHC
Phone: 360-358-2085