=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821788514
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL MOUNTAIN THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2023
-----------------------------------------------------
Last Update Date | 10/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1817 QUEEN ANNE AVE N STE 202
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98109-2876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-333-2343
-----------------------------------------------------
Fax | 206-848-1329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1752 NW MARKET ST # 4340
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98107-5264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-646-3686
-----------------------------------------------------
Fax | 425-429-2417
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | MR. MATTHEW MICHAEL NORDIN
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 206-333-2343
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------