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General NPI Number Information
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NPI Number | 1710530167
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Entity Type | Organization
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Legal Business Name | THERAPEUTIC MIND GROUP, PLLC
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Dates
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Enumeration Date | 07/24/2019
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Last Update Date | 07/24/2019
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Provider Practice Location Address
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Address Line | 12507 NE BEL RED RD STE 103
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City | BELLEVUE
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State | WA
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Zip | 98005-2500
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Country | US
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Telephone | 206-601-1817
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Fax |
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Provider Business Mailing Address
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Address Line | 10507 24TH ST SE
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City | LAKE STEVENS
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State | WA
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Zip | 98258-5663
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Country | US
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Telephone | 206-601-1817
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Fax |
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Authorized Official
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Title or Position | CLINICAL SOCIAL WORKER
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Name | TITO MALTOS
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Credential | MSW
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Telephone | 206-601-1817
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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