MEDICARE: ERIC EIDENS M.A.

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	MC60407079	WA

General Provider Information

NPI Number	:	1619365228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC EIDENS M.A.

Provider Business Mailing Address
First Line	:	2370 130TH AVE NE
Second Line	:	STE 104
City	:	BELLEVUE
State	:	WA
Zip	:	98005-1770
Country	:	US
Telephone Number	:	425-628-2820
Fax Number	:	425-615-6845

Provider Business Practice Location Address
First Line	:	2370 130TH AVE NE
Second Line	:	STE 104
City	:	BELLEVUE
State	:	WA
Zip	:	98005-1770
Country	:	US
Telephone Number	:	425-628-2820
Fax Number	:	425-615-6845

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

Provider Enumeration Date	:	01/05/2015
Last Update Date	:	01/05/2015

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