MEDICARE: MS. ANITA L LARAE 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	101YM0800X	Mental Health Counselor	RC00046731	WA
2	101YM0800X	Mental Health Counselor	LH00010789	WA

General Provider Information

NPI Number	:	1417057100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANITA L LARAE LMHC

Provider Business Mailing Address
First Line	:	PO BOX 236
Second Line	:
City	:	MANCHESTER
State	:	WA
Zip	:	98353-0236
Country	:	US
Telephone Number	:	360-871-4431
Fax Number	:	360-769-5909

Provider Business Practice Location Address
First Line	:	4275 SE MILE HILL DR
Second Line	:	SUITE B
City	:	PORT ORCHARD
State	:	WA
Zip	:	98366-3934
Country	:	US
Telephone Number	:	360-871-4431
Fax Number	:	360-769-5909

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

Provider Enumeration Date	:	09/23/2006
Last Update Date	:	02/03/2010

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