MEDICARE: DEEPWATER WELLNESS MENTAL HEALTH COUNSELING AND ART THERAPY PLLC

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61078648	OTHER	WA	NON-MEDICARE

General Provider Information

NPI Number	:	1700503901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEEPWATER WELLNESS MENTAL HEALTH COUNSELING AND ART THERAPY PLLC

Provider Business Mailing Address
First Line	:	1206 E NORTH ST
Second Line	:
City	:	BELLINGHAM
State	:	WA
Zip	:	98226-4640
Country	:	US
Telephone Number	:	970-426-9862
Fax Number	:

Provider Business Practice Location Address
First Line	:	1206 E NORTH ST
Second Line	:
City	:	BELLINGHAM
State	:	WA
Zip	:	98226-4640
Country	:	US
Telephone Number	:	970-426-9862
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	KELLY L LYNCH
Credential	:	LMHC, ATR-P, MA
Telephone Number	:	970-426-9862

Provider Enumeration Date	:	10/27/2022
Last Update Date	:	10/27/2022

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