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NPI Code Detail

MEDICARE: PHOENIX STAR

MEDICARE: PHOENIX STAR
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health CounselorWA

General Provider Information

NPI Number : 1003779687
Entity Type Code : Individual
Provider Name (Legal Business Name) : PHOENIX STAR
Provider Business Mailing Address
First Line : 4219 SW JUNEAU ST
Second Line :
City : SEATTLE
State : WA
Zip : 98136-1621
Country : US
Telephone Number : 206-207-5395
Fax Number :
Provider Business Practice Location Address
First Line : 4219 SW JUNEAU ST
Second Line :
City : SEATTLE
State : WA
Zip : 98136-1621
Country : US
Telephone Number : 206-207-5395
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/09/2025
Last Update Date : 12/09/2025

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Directions to “ PHOENIX STAR ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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