Provider Demographics
NPI:1962655050
Name:MANSUROV, SHEILA NICOLE (MA, LMHC, SOTP)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:NICOLE
Last Name:MANSUROV
Suffix:
Gender:F
Credentials:MA, LMHC, SOTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11415 NE 128TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034
Mailing Address - Country:US
Mailing Address - Phone:425-298-6223
Mailing Address - Fax:
Practice Address - Street 1:11415 NE 128TH ST STE 100
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6314
Practice Address - Country:US
Practice Address - Phone:425-298-6223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAFC 60206027101Y00000X
WALH60184919101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2039799Medicaid