MEDICARE: SPOKANE THERAPIST LLC

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	101YM0800X	Mental Health Counselor	MC60115047	WA

General Provider Information

NPI Number	:	1396001749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPOKANE THERAPIST LLC

Provider Business Mailing Address
First Line	:	1212 N WASHINGTON ST
Second Line	:	206
City	:	SPOKANE
State	:	WA
Zip	:	99201-2403
Country	:	US
Telephone Number	:	509-209-9486
Fax Number	:	509-232-0883

Provider Business Practice Location Address
First Line	:	1212 N WASHINGTON ST
Second Line	:	206
City	:	SPOKANE
State	:	WA
Zip	:	99201-2403
Country	:	US
Telephone Number	:	509-209-9486
Fax Number	:	509-232-0883

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	LAYNE STOOPS
Credential	:	M.ED., MHCA, NCC
Telephone Number	:	50920299486

Provider Enumeration Date	:	04/10/2012
Last Update Date	:	04/22/2013

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