MEDICARE: DESILEE LYNN MOCK LMHCA

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

General Provider Information

NPI Number	:	1407210776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESILEE LYNN MOCK LMHCA

Provider Business Mailing Address
First Line	:	1411 113TH AVE SE
Second Line	:
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-9784
Country	:	US
Telephone Number	:	425-426-4172
Fax Number	:

Provider Business Practice Location Address
First Line	:	4423 S 3RD AVE
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98203-2515
Country	:	US
Telephone Number	:	425-426-4172
Fax Number	:

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

Provider Enumeration Date	:	04/12/2016
Last Update Date	:	03/12/2017

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