Healthcare Provider Details

I. General information

NPI: 1750217121
Provider Name (Legal Business Name): MR. SHANE BAGUYO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 RAINIER AVE S
SEATTLE WA
98118-1656
US

IV. Provider business mailing address

13022 3RD AVE S
BURIEN WA
98168-2644
US

V. Phone/Fax

Practice location:
  • Phone: 206-536-7011
  • Fax: 206-970-5854
Mailing address:
  • Phone: 206-536-7011
  • Fax: 206-970-5854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCA.MC.61409816
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: