Healthcare Provider Details

I. General information

NPI: 1801130976
Provider Name (Legal Business Name): WASHINGTON STATE PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5105 200TH ST SW STE 100
LYNNWOOD WA
98036-6397
US

IV. Provider business mailing address

3224 75TH DR NE
MARYSVILLE WA
98270-6804
US

V. Phone/Fax

Practice location:
  • Phone: 425-387-6972
  • Fax: 425-377-0701
Mailing address:
  • Phone: 425-387-6972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPY60014648
License Number StateWA

VIII. Authorized Official

Name: DR. BRENDA HAVELLANA
Title or Position: NEUROPSYCHOLOGIST
Credential: PHD
Phone: 425-387-6972