MEDICARE: MR. CALEB DALE VISSER

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1316352594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CALEB DALE VISSER

Provider Business Mailing Address
First Line	:	9 BOSTON ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98109-2320
Country	:	US
Telephone Number	:	360-739-7566
Fax Number	:

Provider Business Practice Location Address
First Line	:	5306 BALLARD AVE NW STE 218
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98107-4366
Country	:	US
Telephone Number	:	360-739-7566
Fax Number	:

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

Provider Enumeration Date	:	06/25/2014
Last Update Date	:	08/06/2020

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