=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720597594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MUSTAFA KHEDHER MOHAMMED MD,MHP,AAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2017
-----------------------------------------------------
Last Update Date | 12/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10803 SE KENT KANGLEY RD STE 101
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98030-7194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-487-7562
-----------------------------------------------------
Fax | 253-487-7562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9630 S 221ST PL
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98031-1946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-487-7562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | CG60490518
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------