Healthcare Provider Details

I. General information

NPI: 1942383898
Provider Name (Legal Business Name): ELLEN D SCHWANNECKE MED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W 4TH AVE
ELLENSBURG WA
98926-3060
US

IV. Provider business mailing address

PO BOX 959
YAKIMA WA
98907-0959
US

V. Phone/Fax

Practice location:
  • Phone: 509-925-9861
  • Fax:
Mailing address:
  • Phone: 509-575-4084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH00007883
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: