Provider Demographics
NPI:1346983244
Name:HAGBOM, BONITA (CO61295697)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:
Last Name:HAGBOM
Suffix:
Gender:F
Credentials:CO61295697
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 N NORTHGATE WAY STE 212
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-9018
Mailing Address - Country:US
Mailing Address - Phone:206-781-2661
Mailing Address - Fax:
Practice Address - Street 1:2111 N NORTHGATE WAY STE 212
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-9018
Practice Address - Country:US
Practice Address - Phone:206-781-2661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61295697101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)