Provider Demographics
NPI:1710038088
Name:VARA, VIDYAVATHI (MED, LMHC)
Entity Type:Individual
Prefix:
First Name:VIDYAVATHI
Middle Name:
Last Name:VARA
Suffix:
Gender:F
Credentials:MED, LMHC
Other - Prefix:
Other - First Name:VIDYA (SHORT NAME)
Other - Middle Name:
Other - Last Name:VARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2309 48TH AVE SW
Mailing Address - Street 2:UNIT B
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-2301
Mailing Address - Country:US
Mailing Address - Phone:206-423-7909
Mailing Address - Fax:
Practice Address - Street 1:1001 4TH AVE
Practice Address - Street 2:#3200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98154-1075
Practice Address - Country:US
Practice Address - Phone:206-423-7909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007873101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA$$$$$$$$$98104A002OtherTRICARE