MEDICARE: VILLAGE WITCH 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1982460952
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGE WITCH THERAPY PLLC

Provider Business Mailing Address
First Line	:	4741 RAINIER AVE S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98118-1657
Country	:	US
Telephone Number	:	206-659-7588
Fax Number	:	888-796-4762

Provider Business Practice Location Address
First Line	:	4741 RAINIER AVE S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98118-1657
Country	:	US
Telephone Number	:	206-659-7588
Fax Number	:	888-796-4762

Authorized Official
Title or Position	:	FOUNDER
Name	:	HORIZON GREENE
Credential	:	LICSW
Telephone Number	:	206-659-7588

Provider Enumeration Date	:	02/26/2024
Last Update Date	:	02/26/2024

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