Healthcare Provider Details

I. General information

NPI: 1235986092
Provider Name (Legal Business Name): EXECUTIVE PSYCHIATRY GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2697 SANDWOOD LN
BLAINE WA
98230-5736
US

IV. Provider business mailing address

100 N HOWARD ST # 5667
SPOKANE WA
99201-0508
US

V. Phone/Fax

Practice location:
  • Phone: 425-626-2419
  • Fax:
Mailing address:
  • Phone: 425-626-2419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS TAMORIA
Title or Position: OWNER
Credential:
Phone: 425-626-2419