=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295450534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA CAROL CONYERS MDIV., BCC-DAA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2022
-----------------------------------------------------
Last Update Date | 10/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1660 S COLUMBIAN WAY
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98108-1532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-277-3753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18329 6TH AVE NE
-----------------------------------------------------
City | POULSBO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98370-8407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-295-9308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP1600X
-----------------------------------------------------
Taxonomy Name | Pastoral Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------