Provider Demographics
NPI:1104251503
Name:BACON, ELIZABETH CANTWELL (M ED, CCC, AAC)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:CANTWELL
Last Name:BACON
Suffix:
Gender:F
Credentials:M ED, CCC, AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12040 98TH AVENUE NE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-6314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12040 98TH AVE NE
Practice Address - Street 2:SUITE 205
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4290
Practice Address - Country:US
Practice Address - Phone:440-668-3373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACL60389203101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor