=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912215914
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEAN LIERLE LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2010
-----------------------------------------------------
Last Update Date | 02/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 793 ERICKSEN AVE NE STE 123
-----------------------------------------------------
City | BAINBRIDGE ISLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98110-1877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-551-0008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 COSGROVE ST NW
-----------------------------------------------------
City | BAINBRIDGE ISLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98110-2758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-780-2900
-----------------------------------------------------
Fax | 206-842-9867
-----------------------------------------------------
=====================================================
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 | LW60003492
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------