Healthcare Provider Details

I. General information

NPI: 1467768333
Provider Name (Legal Business Name): PAMELA ANNE WYSS LICSW, CEAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2010
Last Update Date: 08/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 192ND ST SE W-201
BOTHELL WA
98012-7937
US

IV. Provider business mailing address

2201 192ND ST SE W-201
BOTHELL WA
98012-7937
US

V. Phone/Fax

Practice location:
  • Phone: 425-239-2563
  • Fax: 425-488-7908
Mailing address:
  • Phone: 425-239-2563
  • Fax: 425-488-7908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00005217
License Number StateWA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: