Basic Information
| Provider Information | |||||||||
| NPI: | 1063811701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUSHELLE | ||||||||
| FirstName: | MARIA VICTORIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMHCA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TENORIO | ||||||||
| OtherFirstName: | MARIA VICTORIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3810 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982138810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253498359 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4807 196TH ST SW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980366430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257441216 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2014 | ||||||||
| LastUpdateDate: | 08/19/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MC60426766 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.