=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841334786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEACHANGE HEALTH & WELLNESS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 06/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1915 25TH AVE S UNIT A
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98144-4708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-632-9522
-----------------------------------------------------
Fax | 877-883-1876
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4412 CALIFORNIA AVE SW UNIT 16325
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98116-0816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-632-9522
-----------------------------------------------------
Fax | 206-632-9522
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KATHY J WILMERING
-----------------------------------------------------
Credential | MSW ARNP
-----------------------------------------------------
Telephone | 206-632-9522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | LH0006554
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LH00006554
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | WA30002439
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------