Provider Demographics
NPI:1306919733
Name:HILLERSTROM, P ROGER (MA, LMHC)
Entity type:Individual
Prefix:MR
First Name:P
Middle Name:ROGER
Last Name:HILLERSTROM
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 1:555 DAYTON ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-3601
Mailing Address - Country:US
Mailing Address - Phone:425-774-4673
Mailing Address - Fax:425-774-0690
Practice Address - Street 1:555 DAYTON ST
Practice Address - Street 2:SUITE C
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3601
Practice Address - Country:US
Practice Address - Phone:425-774-4673
Practice Address - Fax:425-774-0690
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00005938101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5842HIOtherREGENCE PROVIDER NO.