# GLACIER LAKE WELLNESS PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1699310284
- **Authorized official:** THOMAS MOORE (PRESIDENT)
- **Authorized official phone:** (541) 345-1722

## Contact information

- **Practice address:** 1400 112TH AVE SE STE 100, BELLEVUE, WA 98004-6901
- **Practice address phone:** (541) 623-0738
- **Mailing address:** 159 N SANGAMON ST STE 200, CHICAGO, IL 60607-2201
- **Mailing address phone:** (309) 397-2415

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 11/07/2019
- **Last updated:** 07/19/2022