MEDICARE: STEPHANIE ANN MOBERG M.A.

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	106H00000X	Marriage & Family Therapist	MG60282607	WA

General Provider Information

NPI Number	:	1346523669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE ANN MOBERG M.A.

Provider Business Mailing Address
First Line	:	1817 QUEEN ANNE AVE N STE 309
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98109-2876
Country	:	US
Telephone Number	:	206-351-2291
Fax Number	:

Provider Business Practice Location Address
First Line	:	1817 QUEEN ANNE AVE N STE 309
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98109-2876
Country	:	US
Telephone Number	:	206-351-2291
Fax Number	:

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

Provider Enumeration Date	:	09/22/2011
Last Update Date	:	10/01/2012

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