Healthcare Provider Details

I. General information

NPI: 1689349011
Provider Name (Legal Business Name): MICHAEL JOHN VIVEIROS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 NW MAPLE ST STE 210
ISSAQUAH WA
98027-8127
US

IV. Provider business mailing address

1740 NW MAPLE ST STE 210
ISSAQUAH WA
98027-8127
US

V. Phone/Fax

Practice location:
  • Phone: 425-224-7307
  • Fax:
Mailing address:
  • Phone: 425-224-7307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSYC.PY.70097641
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: