=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164276531
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARBORLIGHT PSYCHOTHERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2024
-----------------------------------------------------
Last Update Date | 04/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 S DAWSON ST STE 103
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98118-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-492-4805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1106 29TH AVE
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98122-5010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-920-6821
-----------------------------------------------------
Fax | 626-884-1516
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | JODI RUBINSTEIN
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 360-492-4805
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------