=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588105506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORCA COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2017
-----------------------------------------------------
Last Update Date | 03/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6957 CALIFORNIA AVE SW
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98136-1953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-390-4303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8106 35TH AVE SW
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98126-3455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-351-1059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | ANDREA BROADWATER
-----------------------------------------------------
Credential | MA LMHC MHP CMHS
-----------------------------------------------------
Telephone | 425-351-1059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LH60620333
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------