Healthcare Provider Details

I. General information

NPI: 1598280364
Provider Name (Legal Business Name): PACIFIC NORTHWEST BEHAVIORAL HEALTH SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2017
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22500 SE 64TH PL STE G-150
ISSAQUAH WA
98027-8111
US

IV. Provider business mailing address

23515 NE NOVELTY HILL RD SUITE #B221- 159
REDMOND WA
98053
US

V. Phone/Fax

Practice location:
  • Phone: 425-686-9509
  • Fax: 425-686-9509
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number60428413
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number60428413
License Number StateWA

VIII. Authorized Official

Name: DAISY VERGARA
Title or Position: THERAPIST
Credential: M.S.
Phone: 425-686-9509