Healthcare Provider Details

I. General information

NPI: 1629050745
Provider Name (Legal Business Name): BONITA SHUFFAIN SIEGEL LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: BONITA SHUFFAIN SIEGEL MSW

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15029 BOTHELL WAY NE SUITE 300
LAKE FOREST PARK WA
98155-7663
US

IV. Provider business mailing address

15029 BOTHELL WAY NE SUITE 300
LAKE FOREST PARK WA
98155-7663
US

V. Phone/Fax

Practice location:
  • Phone: 206-364-0075
  • Fax: 206-364-7607
Mailing address:
  • Phone: 206-364-0075
  • Fax: 206-364-7607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: