=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194176420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZACHARY SHAEFFER LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2016
-----------------------------------------------------
Last Update Date | 09/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3420 NE 147TH ST APT 4
-----------------------------------------------------
City | LAKE FOREST PARK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98155-7850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-713-6826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 821 HOWARD RD SE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20020-5805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 60963612
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LC50080561
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------