Healthcare Provider Details

I. General information

NPI: 1073059259
Provider Name (Legal Business Name): KOSUKE NIITSU PHD, ARNP, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 10/15/2023
Certification Date: 10/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17927 113TH AVE NE
BOTHELL WA
98011-7909
US

IV. Provider business mailing address

18115 CAMPUS WAY NE BOX 358555
BOTHELL WA
98011
US

V. Phone/Fax

Practice location:
  • Phone: 425-352-3183
  • Fax: 425-352-3581
Mailing address:
  • Phone: 425-352-3183
  • Fax: 425-352-3581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberC-APN.0000823-C-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberG145896
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number111689
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60989975
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: