Healthcare Provider Details

I. General information

NPI: 1184263741
Provider Name (Legal Business Name): ALASKA TELEPSYCHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E FIREWEED LN STE 201
ANCHORAGE AK
99503-2100
US

IV. Provider business mailing address

3705 ARCTIC BLVD # 1058
ANCHORAGE AK
99503-5774
US

V. Phone/Fax

Practice location:
  • Phone: 907-885-6288
  • Fax: 907-290-8525
Mailing address:
  • Phone: 907-885-6288
  • Fax: 907-290-8525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE ALLEN
Title or Position: COO
Credential: COO
Phone: 907-885-6288