Provider Demographics
NPI:1285067942
Name:BEZUSKO, SHANAE MARIE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:SHANAE
Middle Name:MARIE
Last Name:BEZUSKO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:SHANAE
Other - Middle Name:MARIE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 88657
Mailing Address - Street 2:
Mailing Address - City:STEILACOOM
Mailing Address - State:WA
Mailing Address - Zip Code:98388-0657
Mailing Address - Country:US
Mailing Address - Phone:971-314-9513
Mailing Address - Fax:
Practice Address - Street 1:10316 107TH AVENUE CT
Practice Address - Street 2:
Practice Address - City:ANDERSON ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98303-8629
Practice Address - Country:US
Practice Address - Phone:971-314-9513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-16
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WASC60479931104100000X
WALW607884981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker