MEDICARE: LARA VANDER WOUDE LMHC

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
1	390200000X	Student in an Organized Health Care Education/Training Program
2	101YM0800X	Mental Health Counselor	MHCA.MC.61163891	WA
3	101YM0800X	Mental Health Counselor	LH61438845	WA

General Provider Information

NPI Number	:	1053951160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARA VANDER WOUDE LMHC

Provider Business Mailing Address
First Line	:	2711 E MADISON ST STE 211
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98112-4763
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2711 E MADISON ST STE 211
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98112-4763
Country	:	US
Telephone Number	:	206-486-4843
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2020
Last Update Date	:	07/12/2023

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