Healthcare Provider Details

I. General information

NPI: 1902097009
Provider Name (Legal Business Name): PUGET SOUND PSYCHIATRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10634 E RIVERSIDE DR SUITE 130
BOTHELL WA
98011-3757
US

IV. Provider business mailing address

10634 E RIVERSIDE DR SUITE 130
BOTHELL WA
98011-3757
US

V. Phone/Fax

Practice location:
  • Phone: 425-806-5021
  • Fax:
Mailing address:
  • Phone: 425-806-5021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

# 1
Identifier1112333
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name: REBECCA LYN PETERSON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 425-802-2861