=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053795302
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IG THERAPY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2015
-----------------------------------------------------
Last Update Date | 07/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22626 NE INGLEWOOD HILL RD APT 737
-----------------------------------------------------
City | SAMMAMISH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98074-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-985-2134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22626 NE INGLEWOOD HILL RD APT 737
-----------------------------------------------------
City | SAMMAMISH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98074-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-985-2134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ESPERANZA IVONNE GARIBAY
-----------------------------------------------------
Credential | LMHCA,MHP,EMMHS,CMHS
-----------------------------------------------------
Telephone | 425-985-2134
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | MC60219702
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | MC60219702
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MC60219702
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------