Healthcare Provider Details

I. General information

NPI: 1790938355
Provider Name (Legal Business Name): SHAUNTAE WILLIS LICSW, CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 BOREN AVE SUITE1300
SEATTLE WA
98104-3595
US

IV. Provider business mailing address

901 BOREN AVE SUITE 1300
SEATTLE WA
98104-3595
US

V. Phone/Fax

Practice location:
  • Phone: 206-619-0028
  • Fax:
Mailing address:
  • Phone: 206-619-0028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP 00005642
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW 60003495
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: