Healthcare Provider Details

I. General information

NPI: 1235575861
Provider Name (Legal Business Name): PROFESSIONAL RECREATION ORGANIZATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 148TH AVE NE
BELLEVUE WA
98007-3120
US

IV. Provider business mailing address

4455 148TH AVE NE
BELLEVUE WA
98007-3120
US

V. Phone/Fax

Practice location:
  • Phone: 425-869-4746
  • Fax: 425-869-5285
Mailing address:
  • Phone: 425-869-4746
  • Fax: 425-869-5285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number600541508
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number600541508
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number600541508
License Number StateWA

VIII. Authorized Official

Name: MS. DEBBIE BECKER
Title or Position: SR DIRECTOR OF ACCOUNTING
Credential:
Phone: 425-869-4746