MEDICARE: MS. LAURA NICOLE EDELSTEIN MA, CDP

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	CP60080404	WA
2	101YM0800X	Mental Health Counselor	LH60537126	WA

General Provider Information

NPI Number	:	1558702936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURA NICOLE EDELSTEIN MA, CDP

Provider Business Mailing Address
First Line	:	19435 68TH AVE S STE S109
Second Line	:
City	:	KENT
State	:	WA
Zip	:	98032-2114
Country	:	US
Telephone Number	:	425-251-1933
Fax Number	:	425-251-4996

Provider Business Practice Location Address
First Line	:	19435 68TH AVE S STE S109
Second Line	:
City	:	KENT
State	:	WA
Zip	:	98032-2114
Country	:	US
Telephone Number	:	425-251-1933
Fax Number	:	425-251-4996

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

Provider Enumeration Date	:	07/12/2013
Last Update Date	:	12/11/2015

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