=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053630442
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN PETER BOGAN M.A., L.M.H.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2010
-----------------------------------------------------
Last Update Date | 05/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6407 FAUNTLEROY S.W.
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98136-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-463-3050
-----------------------------------------------------
Fax | 206-463-6137
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13930-S.W. POHL ROAD
-----------------------------------------------------
City | VASHON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98070-8712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-463-3050
-----------------------------------------------------
Fax | 206-463-6137
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | LH00004352
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------