Healthcare Provider Details

I. General information

NPI: 1245519503
Provider Name (Legal Business Name): LAURA LOGAN BETHEL RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 08/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 MCGILVRA BLVD E
SEATTLE WA
98112-5047
US

IV. Provider business mailing address

541 MCGILVRA BLVD E
SEATTLE WA
98112-5047
US

V. Phone/Fax

Practice location:
  • Phone: 206-328-6076
  • Fax:
Mailing address:
  • Phone: 206-328-6076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberPT 00002431
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberPT 00002431
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: