1770527616 NPI number — PATRICIA DIANE LONG-BROHM MSW, LICSW

Table of content: PATRICIA DIANE LONG-BROHM MSW, LICSW (NPI 1770527616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770527616 NPI number — PATRICIA DIANE LONG-BROHM MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONG-BROHM
Provider First Name:
PATRICIA
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LONG
Provider Other First Name:
PATRICIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, LICSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770527616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6523 CALIFORNIA AVE SW # B177
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98136-1833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-865-9645
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4215 SW SULLIVAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98136-2365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-865-9645
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  20819 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LW60503508 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 32655011 . This is a "BCBS OF KC" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".