Healthcare Provider Details

I. General information

NPI: 1992176085
Provider Name (Legal Business Name): GLEN DAWSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19803 N CREEK PKWY STE 205
BOTHELL WA
98011-5014
US

IV. Provider business mailing address

19803 N CREEK PKWY STE 205
BOTHELL WA
98011-5014
US

V. Phone/Fax

Practice location:
  • Phone: 206-588-5725
  • Fax:
Mailing address:
  • Phone: 206-588-5725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY61142927
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: