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General NPI Number Information
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NPI Number | 1790160752
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Entity Type | Organization
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Legal Business Name | WISE MIND BEHAVIORAL THERAPY LLC
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Dates
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Enumeration Date | 07/20/2015
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Last Update Date | 07/20/2015
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Provider Practice Location Address
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Address Line | 6505 218TH ST SW STE 14
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City | MOUNTLAKE TERRACE
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State | WA
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Zip | 98043-2135
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Country | US
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Telephone | 206-883-4906
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Fax | 206-316-2309
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Provider Business Mailing Address
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Address Line | 6505 218TH ST SW STE 14
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City | MOUNTLAKE TERRACE
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State | WA
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Zip | 98043-2135
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Country | US
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Telephone | 206-883-4906
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Fax | 206-316-2309
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Authorized Official
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Title or Position | OWNER
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Name | MS. MEGAN O'LAUGHLIN
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Credential | LICSW
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Telephone | 206-883-4906
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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 | LW60222786
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License Number State | WA
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