Healthcare Provider Details

I. General information

NPI: 1386749430
Provider Name (Legal Business Name): LAURA KENNA HEGINBOTTOM LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE BOX 359960
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

325 9TH AVE BOX 359750
SEATTLE WA
98104-2420
US

V. Phone/Fax

Practice location:
  • Phone: 206-731-3000
  • Fax:
Mailing address:
  • Phone: 206-744-9888
  • Fax: 206-744-9773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00005966
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: