=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467080499
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUZANNE MARIE CAMPICHE MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2020
-----------------------------------------------------
Last Update Date | 03/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12040 NE 128TH ST
-----------------------------------------------------
City | KIRKLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98034-3013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-669-4923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8684 ISLAND DR S
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98118-4734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-669-4923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LW60985209
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------