Healthcare Provider Details

I. General information

NPI: 1396118360
Provider Name (Legal Business Name): HODA TABATABAEI-MOGHADDAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 01/11/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7202 NE HIGHWAY 99 STE 106-4392
VANCOUVER WA
98665-8932
US

IV. Provider business mailing address

7202 NE HIGHWAY 99 STE 106-4392
VANCOUVER WA
98665-8932
US

V. Phone/Fax

Practice location:
  • Phone: 253-501-6019
  • Fax:
Mailing address:
  • Phone: 253-501-6019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number60996653
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number60996653
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: