Provider Demographics
NPI:1215135520
Name:EILERTSEN, JOHN M IV (MS, LMHC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:EILERTSEN
Suffix:IV
Gender:M
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 196TH ST SW
Mailing Address - Street 2:STE. 103
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6152
Mailing Address - Country:US
Mailing Address - Phone:425-239-6689
Mailing Address - Fax:425-771-7865
Practice Address - Street 1:5108 196TH ST SW
Practice Address - Street 2:STE. 103
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6152
Practice Address - Country:US
Practice Address - Phone:425-239-6689
Practice Address - Fax:425-771-7865
Is Sole Proprietor?:No
Enumeration Date:2007-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006020101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health