=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245479518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUDITH MENDENHALL, MSW, LICSW, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2009
-----------------------------------------------------
Last Update Date | 02/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 470 FRONT ST N
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-300-5008
-----------------------------------------------------
Fax | 425-881-6707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 470 FRONT ST N
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-300-5008
-----------------------------------------------------
Fax | 425-881-6707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND MANAGAER
-----------------------------------------------------
Name | MS. JUDITH MENDENHALL
-----------------------------------------------------
Credential | MSW, LICSW, PLLC
-----------------------------------------------------
Telephone | 206-300-5008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | LW00005376
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------