Healthcare Provider Details

I. General information

NPI: 1821607417
Provider Name (Legal Business Name): EDMOND DENNIS IV MSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 SW 320TH ST
FEDERAL WAY WA
98023-2292
US

IV. Provider business mailing address

3430 SW 320TH ST
FEDERAL WAY WA
98023-2292
US

V. Phone/Fax

Practice location:
  • Phone: 253-289-6099
  • Fax: 253-231-7251
Mailing address:
  • Phone: 253-289-6099
  • Fax: 253-231-7251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMG61416353
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: