MEDICARE: NORTHWEST PSYCHOLOGICAL RESOURCES LLC

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	RC49825	WA
2	101Y00000X	Counselor	LH4032	WA
3	103T00000X	Psychologist	PY2237	WA
4	103T00000X	Psychologist	PY2966	WA
5	103T00000X	Psychologist	PY3397	WA
6	103T00000X	Psychologist	PY436	WA
7	103T00000X	Psychologist	PY3263	WA
8	103T00000X	Psychologist	PY2721	WA
9	103T00000X	Psychologist	PY1687	WA
10	103T00000X	Psychologist	PY2823	WA
11	103T00000X	Psychologist	PY1269	WA
12	1041C0700X	Clinical Social Worker	LW4474	WA
13	1041C0700X	Clinical Social Worker	SW40002261	WA
14	103G00000X	Clinical Neuropsychologist	PY1656	WA

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0126624	OTHER	WA	LABOR AND INDUSTRIES
2	112359	OTHER	WA	KAISER
3	0126624	OTHER	WA	CRIME VICTIMS

NPI Number	:	1811079049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST PSYCHOLOGICAL RESOURCES LLC

Provider Business Mailing Address
First Line	:	945 11TH AVE
Second Line	:	SUITE B
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2555
Country	:	US
Telephone Number	:	360-414-8600
Fax Number	:	360-636-7372

Provider Business Practice Location Address
First Line	:	945 11TH AVE
Second Line	:	SUITE B
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2555
Country	:	US
Telephone Number	:	360-414-8600
Fax Number	:	360-636-7372

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. ELIZABETH J MCNABB
Credential	:
Telephone Number	:	360-414-8600

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	12/20/2007