Basic Information
| Provider Information | |||||||||
| NPI: | 1316238678 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MINDFUL SUPPORT SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MINDFUL THERAPY GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6505 216TH ST SW STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOUNTLAKE TERRACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980432089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256407009 | ||||||||
| FaxNumber: | 4256409600 | ||||||||
| Practice Location | |||||||||
| Address1: | 6505 216TH ST SW STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOUNTLAKE TERRACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980432089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256407009 | ||||||||
| FaxNumber: | 4256786455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2011 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRAIN | ||||||||
| AuthorizedOfficialFirstName: | DEREK | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4256407009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LICSW | ||||||||
| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LH 00006954 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | LW 60165078 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | LF 60159362 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 1041C0700X | LW 00009354 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.