=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013267251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOONTREE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2012
-----------------------------------------------------
Last Update Date | 09/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3305 MAIN ST STE 23
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98663-2234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-949-2727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9208 NE HIGHWAY 99 STE 107 #110
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98665-8986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-949-2727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MR. TROY D WILLETT
-----------------------------------------------------
Credential | MS, LMHC
-----------------------------------------------------
Telephone | 360-949-2727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LH60169232
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------