Provider Demographics
NPI:1174179162
Name:BONGHI, ELIZABETH MAE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MAE
Last Name:BONGHI
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 1:2430 NW MYHRE RD # 101
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7669
Mailing Address - Country:US
Mailing Address - Phone:360-328-5054
Mailing Address - Fax:
Practice Address - Street 1:897 TAURNIC PL NW
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2760
Practice Address - Country:US
Practice Address - Phone:206-790-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABONGHEM066OE106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician