MEDICARE: ISLAND CENTER FOR COMPLEMENTARY MEDICINE INC P S

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LH00003885	WA
2	171100000X	Acupuncturist	AC00000208	WA
3	101YM0800X	Mental Health Counselor	LH00003885	WA

General Provider Information

NPI Number	:	1437270675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND CENTER FOR COMPLEMENTARY MEDICINE INC P S

Provider Business Mailing Address
First Line	:	6826 28TH AVE NE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-7145
Country	:	US
Telephone Number	:	206-525-0750
Fax Number	:	206-524-6530

Provider Business Practice Location Address
First Line	:	4649 SUNNYSIDE AVE N
Second Line	:	SUITE 343
City	:	SEATTLE
State	:	WA
Zip	:	98103-6900
Country	:	US
Telephone Number	:	206-215-0534
Fax Number	:	206-524-6530

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. DEBORAH ROSE HOUSEWORTH
Credential	:	L.AC.
Telephone Number	:	206-525-0750

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	11/03/2011

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