Healthcare Provider Details

I. General information

NPI: 1316715485
Provider Name (Legal Business Name): KETCHINAE PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 12/18/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22722 29TH DR SE STE 100
BOTHELL WA
98021-4420
US

IV. Provider business mailing address

100 N HOWARD ST STE R
SPOKANE WA
99201-0508
US

V. Phone/Fax

Practice location:
  • Phone: 425-484-9352
  • Fax:
Mailing address:
  • Phone: 425-484-9352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. BONNER DOBBS
Title or Position: OWNER
Credential: PSYD
Phone: 425-484-9352