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Organization
GLACIER LAKE WELLNESS PLLC
Active
Organization
GLACIER LAKE WELLNESS PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
THOMAS MOORE (PRESIDENT)
(541) 345-1722
Entity
Organization
Contact information
Practice address
1400 112TH AVE SE STE 100, BELLEVUE, WA 98004-6901
(541) 623-0738
Mailing address
159 N SANGAMON ST STE 200, CHICAGO, IL 60607-2201
(309) 397-2415
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
NULL
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
—
Other
Enumeration date
11/07/2019
Last updated
07/19/2022
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