Provider Demographics
NPI:1437351335
Name:ROUSTAEI, OMID (MA LMHC)
Entity Type:Individual
Prefix:MR
First Name:OMID
Middle Name:
Last Name:ROUSTAEI
Suffix:
Gender:M
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5416 17TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98106-1540
Mailing Address - Country:US
Mailing Address - Phone:206-228-6797
Mailing Address - Fax:
Practice Address - Street 1:5416 17TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98106-1540
Practice Address - Country:US
Practice Address - Phone:206-228-6797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-03
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60151748101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health