Healthcare Provider Details

I. General information

NPI: 1770769648
Provider Name (Legal Business Name): ANTONIA ROSZITA MEJORADO LMHC, SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9575 ETHAN WADE WAY SE
SNOQUALMIE WA
98065-9577
US

IV. Provider business mailing address

PO BOX 1470
SNOQUALMIE WA
98065-1470
US

V. Phone/Fax

Practice location:
  • Phone: 425-831-5425
  • Fax: 425-831-5428
Mailing address:
  • Phone: 206-227-0261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00005924
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60647519
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: