Provider Demographics
NPI:1952614646
Name:BRACKEBUSCH, KARIN E (LMHC)
Entity Type:Individual
Prefix:
First Name:KARIN
Middle Name:E
Last Name:BRACKEBUSCH
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1393
Mailing Address - Street 2:
Mailing Address - City:DUVALL
Mailing Address - State:WA
Mailing Address - Zip Code:98019-1393
Mailing Address - Country:US
Mailing Address - Phone:206-678-7595
Mailing Address - Fax:206-792-3629
Practice Address - Street 1:15315 1ST AVE NE
Practice Address - Street 2:1393
Practice Address - City:DUVALL
Practice Address - State:WA
Practice Address - Zip Code:98019-6339
Practice Address - Country:US
Practice Address - Phone:206-678-7595
Practice Address - Fax:206-792-3629
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-22
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC.60168632101Y00000X, 101YM0800X, 101YP1600X
WALH60531448101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2042475Medicaid