MEDICARE: MR. OMID ROUSTAEI MA 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	LH60151748	WA

General Provider Information

NPI Number	:	1437351335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OMID ROUSTAEI MA LMHC

Provider Business Mailing Address
First Line	:	5416 17TH AVE SW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98106-1540
Country	:	US
Telephone Number	:	206-228-6797
Fax Number	:

Provider Business Practice Location Address
First Line	:	5416 17TH AVE SW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98106-1540
Country	:	US
Telephone Number	:	206-228-6797
Fax Number	:

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

Provider Enumeration Date	:	06/03/2007
Last Update Date	:	04/12/2011

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