Healthcare Provider Details

I. General information

NPI: 1811079049
Provider Name (Legal Business Name): NORTHWEST PSYCHOLOGICAL RESOURCES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 11TH AVE SUITE B
LONGVIEW WA
98632-2555
US

IV. Provider business mailing address

945 11TH AVE SUITE B
LONGVIEW WA
98632-2555
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-8600
  • Fax: 360-636-7372
Mailing address:
  • Phone: 360-414-8600
  • Fax: 360-636-7372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberRC49825
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLH4032
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY2237
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY2966
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY3397
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY436
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY3263
License Number StateWA
# 8
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY2721
License Number StateWA
# 9
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY1687
License Number StateWA
# 10
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY2823
License Number StateWA
# 11
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY1269
License Number StateWA
# 12
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW4474
License Number StateWA
# 13
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW40002261
License Number StateWA
# 14
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY1656
License Number StateWA

VIII. Authorized Official

Name: MS. ELIZABETH J MCNABB
Title or Position: OFFICE MANAGER
Credential:
Phone: 360-414-8600