MEDICARE: THOMAS EDWARD BISENIUS LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CP00000487	WA
2	1041C0700X	Clinical Social Worker	LW60826217	WA

General Provider Information

NPI Number	:	1376012260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS EDWARD BISENIUS LICSW

Provider Business Mailing Address
First Line	:	PO BOX 745
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99210-0745
Country	:	US
Telephone Number	:	509-534-6479
Fax Number	:

Provider Business Practice Location Address
First Line	:	1960 N HOLY NAMES CT
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99224-5803
Country	:	US
Telephone Number	:	509-358-4271
Fax Number	:	509-455-4988

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2018
Last Update Date	:	11/20/2018

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