Provider Demographics
NPI:1255754594
Name:BOTZHEIM, CIERA CAPRICE (PSYD)
Entity type:Individual
Prefix:
First Name:CIERA
Middle Name:CAPRICE
Last Name:BOTZHEIM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EASTERN STATE HOSPITAL
Mailing Address - Street 2:PO BOX 800
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-0800
Mailing Address - Country:US
Mailing Address - Phone:509-565-4000
Mailing Address - Fax:509-565-4705
Practice Address - Street 1:EASTERN STATE HOSPITAL
Practice Address - Street 2:850 MAPLE STREET
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022-0800
Practice Address - Country:US
Practice Address - Phone:509-565-4000
Practice Address - Fax:509-565-4705
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WAPY60820221103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health