=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235596842
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EATING RECOVERY CENTER OF WASHINGTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2016
-----------------------------------------------------
Last Update Date | 01/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 114TH AVE SE
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-6950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-451-8501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4130 JASPERWOOD CT
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80920-6620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MATT CROCKETT
-----------------------------------------------------
Credential | MSW MHA
-----------------------------------------------------
Telephone | 425-451-1134
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LH60617943
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------