=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962877266
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELULEKI NCUBE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2015
-----------------------------------------------------
Last Update Date | 09/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 651 STRANDER BLVD STE B-110
-----------------------------------------------------
City | TUKWILA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98188-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-850-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1315 N 182ND PL
-----------------------------------------------------
City | SHORELINE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98133-4432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-288-4017
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LF61113547
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------