1245489467 NPI number — MISS SHALEENA BERTRAM M.S.W., L.M.H.C.

Table of content: (NPI 1578149407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245489467 NPI number — MISS SHALEENA BERTRAM M.S.W., L.M.H.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERTRAM
Provider First Name:
SHALEENA
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
M.S.W., L.M.H.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245489467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2592 KWINA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98226-9278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-312-2019
Provider Business Mailing Address Fax Number:
360-380-6976

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2665 KWINA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98226-9291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-312-2019
Provider Business Practice Location Address Fax Number:
360-380-6976
Provider Enumeration Date:
09/11/2008

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: 101YM0800X , with the licence number:  LH60167632 , 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)





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