Basic Information
| Provider Information | |||||||||
| NPI: | 1295202547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHN | ||||||||
| FirstName: | FRAUKE | ||||||||
| MiddleName: | DOROTHEA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHN | ||||||||
| OtherFirstName: | FRAUKE | ||||||||
| OtherMiddleName: | DOROTHEA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9708 NE 1ST STREET | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4243861922 | ||||||||
| FaxNumber: | 2069012010 | ||||||||
| Practice Location | |||||||||
| Address1: | 9708 NE 1ST STREET | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4243861922 | ||||||||
| FaxNumber: | 2063022610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2018 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/31/2019 | ||||||||
| NPIReactivationDate: | 01/22/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MC61005022 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.