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General NPI Number Information
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NPI Number | 1497101158
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Entity Type | Organization
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Legal Business Name | ETERNAL TREE OF LIFE, LLC
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Dates
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Enumeration Date | 05/11/2016
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Last Update Date | 05/11/2016
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Provider Practice Location Address
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Address Line | 1117 A ST
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City | TACOMA
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State | WA
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Zip | 98402-5003
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Country | US
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Telephone | 253-336-4188
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Fax |
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Provider Business Mailing Address
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Address Line | 1911 SW CAMPUS DR STE 385
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City | FEDERAL WAY
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State | WA
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Zip | 98023-6473
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Country | US
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Telephone | 253-336-4188
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH COUNSELOR
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Name | HEATHER PARKER
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Credential | LMHC
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Telephone | 253-336-4188
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LH 00011066
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License Number State | WA
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