=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134845480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADRONA COUNSELING INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2022
-----------------------------------------------------
Last Update Date | 10/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 434 MADRONA ST STE C
-----------------------------------------------------
City | EASTSOUND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98245-8573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-413-8544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 951
-----------------------------------------------------
City | EASTSOUND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98245-0951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-413-8544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR / CEO
-----------------------------------------------------
Name | CASSANDRA PERRYMAN
-----------------------------------------------------
Credential | PHD, LMHC, APCC
-----------------------------------------------------
Telephone | 916-413-8544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------