Basic Information
Provider Information | |||||||||
NPI: | 1750655577 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAH | ||||||||
FirstName: | AMELIA | ||||||||
MiddleName: | LOUISE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | BSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KENT | ||||||||
OtherFirstName: | AMELIA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1110 HOYT AVE | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982011530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252327015 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4445 TALBOT RD S | ||||||||
Address2: |   | ||||||||
City: | RENTON | ||||||||
State: | WA | ||||||||
PostalCode: | 980556219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4256903414 | ||||||||
FaxNumber: | 4256909414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/24/2012 | ||||||||
LastUpdateDate: | 03/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LW61100371 | WA | Y |   | Behavioral Health & Social Service Providers | Social Worker |   | 104100000X |   |   | N |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 210012 | 05 | WA |   | MEDICAID |