Provider Demographics
NPI:1659774628
Name:NDEGWA RENNEBOHM, ALEXANDRA MARIE
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:MARIE
Last Name:NDEGWA RENNEBOHM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:MARIE
Other - Last Name:NDEGWA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 SW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2603
Mailing Address - Country:US
Mailing Address - Phone:206-630-1680
Mailing Address - Fax:
Practice Address - Street 1:1200 SW 27TH ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2603
Practice Address - Country:US
Practice Address - Phone:206-630-1680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW61118940104100000X, 1041C0700X
WASC60713008101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical