MEDICARE: DR. URSULA WHITESIDE PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY60265517	WA

General Provider Information

NPI Number	:	1689949638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. URSULA WHITESIDE PHD

Provider Business Mailing Address
First Line	:	2331 E MADISON ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98112-5416
Country	:	US
Telephone Number	:	206-679-6349
Fax Number	:

Provider Business Practice Location Address
First Line	:	2331 E MADISON ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98112-5416
Country	:	US
Telephone Number	:	206-679-6349
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2012
Last Update Date	:	12/26/2016

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