=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750508891
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WANDA JEANETTE BOE LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 02/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 NW GILMAN BLVD # 2118
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-5394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-985-2396
-----------------------------------------------------
Fax | 425-888-0372
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1387
-----------------------------------------------------
City | NORTH BEND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98045-1387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-985-2396
-----------------------------------------------------
Fax | 425-888-0372
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LF00001411
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------