Healthcare Provider Details

I. General information

NPI: 1023006061
Provider Name (Legal Business Name): PHD#2 OF SNOHOMISH COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21601 76TH AVE W
EDMONDS WA
98026-7507
US

IV. Provider business mailing address

21601 76TH AVE W
EDMONDS WA
98026-7507
US

V. Phone/Fax

Practice location:
  • Phone: 425-640-4000
  • Fax: 425-640-4432
Mailing address:
  • Phone: 425-640-4000
  • Fax: 425-640-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License NumberH-138
License Number StateWA

VIII. Authorized Official

Name: MR. GARY WANGSMO
Title or Position: CFO
Credential:
Phone: 425-640-4113