Provider Demographics
NPI:1043620925
Name:P. BONEBRAKE MD CHILD AND ADOLESCENT PSYCHIATRY LLC
Entity Type:Organization
Organization Name:P. BONEBRAKE MD CHILD AND ADOLESCENT PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PORTIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONEBRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-449-9710
Mailing Address - Street 1:PO BOX 113
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98083-0113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17220 127TH PL NE STE 101A
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-7965
Practice Address - Country:US
Practice Address - Phone:425-449-9710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60097435261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health