Healthcare Provider Details

I. General information

NPI: 1598645764
Provider Name (Legal Business Name): ETHAN SIEK BOUN LSWAIC, MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2025
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14803 15TH AVE NE
SHORELINE WA
98155-7110
US

IV. Provider business mailing address

14803 15TH AVE NE
SHORELINE WA
98155-7110
US

V. Phone/Fax

Practice location:
  • Phone: 206-362-7282
  • Fax:
Mailing address:
  • Phone: 206-631-8819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWIA.SC.70115692
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: