MEDICARE: MS. VICTORIA GAST HEEMSTRA MA

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	RC00017200	WA

General Provider Information

NPI Number	:	1578770798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VICTORIA GAST HEEMSTRA MA

Provider Business Mailing Address
First Line	:	6403 NE RALSTON RD
Second Line	:
City	:	BAINBRIDGE ISLAND
State	:	WA
Zip	:	98110-1032
Country	:	US
Telephone Number	:	206-780-0423
Fax Number	:

Provider Business Practice Location Address
First Line	:	6403 NE RALSTON RD
Second Line	:
City	:	BAINBRIDGE ISLAND
State	:	WA
Zip	:	98110-1032
Country	:	US
Telephone Number	:	206-780-0423
Fax Number	:

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

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	07/08/2007

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