MEDICARE: ERIC ROBERT HASSELBLAD

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

General Provider Information

NPI Number	:	1619448586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC ROBERT HASSELBLAD

Provider Business Mailing Address
First Line	:	PO BOX 2906
Second Line	:
City	:	BELFAIR
State	:	WA
Zip	:	98528-2906
Country	:	US
Telephone Number	:	509-290-3411
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 W FRANKLIN ST STE A
Second Line	:
City	:	SHELTON
State	:	WA
Zip	:	98584-3518
Country	:	US
Telephone Number	:	360-462-3016
Fax Number	:

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

Provider Enumeration Date	:	12/17/2018
Last Update Date	:	12/17/2018

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