Provider Demographics
NPI:1083244644
Name:BENGTSON, AUDREY JANE
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:JANE
Last Name:BENGTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 TIPSOO LOOP S
Mailing Address - Street 2:
Mailing Address - City:RAINIER
Mailing Address - State:WA
Mailing Address - Zip Code:98576-9745
Mailing Address - Country:US
Mailing Address - Phone:360-359-2082
Mailing Address - Fax:
Practice Address - Street 1:3773 MARTIN WAY E STE 107
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4400
Practice Address - Country:US
Practice Address - Phone:360-688-7312
Practice Address - Fax:360-688-7318
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61019437101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)