Provider Demographics
NPI:1518473099
Name:AUSTIN, BRUCE WAYNE SR (CDP)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:WAYNE
Last Name:AUSTIN
Suffix:SR
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9930 EVERGREEN WAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-3883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9930 EVERGREEN WAY STE Z150
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-3889
Practice Address - Country:US
Practice Address - Phone:425-347-5121
Practice Address - Fax:425-353-6425
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60437219101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP60437219OtherCHEMICAL DEPENDENCY PROFESSIONAL
WACP60437219Medicaid