Basic Information
Provider Information | |||||||||
NPI: | 1730420977 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BIGELOW | ||||||||
FirstName: | DONOVAN | ||||||||
MiddleName: | RAYMOND | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 OAKESDALE AVE SW | ||||||||
Address2: | #104 | ||||||||
City: | RENTON | ||||||||
State: | WA | ||||||||
PostalCode: | 980575226 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252285336 | ||||||||
FaxNumber: | 4252284540 | ||||||||
Practice Location | |||||||||
Address1: | 5837 221ST PL SE | ||||||||
Address2: |   | ||||||||
City: | ISSAQUAH | ||||||||
State: | WA | ||||||||
PostalCode: | 980278917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253910887 | ||||||||
FaxNumber: | 4253917014 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/13/2013 | ||||||||
LastUpdateDate: | 03/13/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LH60117655 | WA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.