=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225457419
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATIE MAYNARD MSW, LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2014
-----------------------------------------------------
Last Update Date | 07/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1707 N 45TH ST SUITE 100
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98103-6847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-835-3698
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1707 N 45TH ST SUITE 100
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98103-6847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-835-3698
-----------------------------------------------------
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 | LW00007955
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------