Healthcare Provider Details

I. General information

NPI: 1609585595
Provider Name (Legal Business Name): SHADES OF GRACE EMDR, EQUINE, IFS THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2022
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

599 NW WALKER RD
POULSBO WA
98370-8140
US

IV. Provider business mailing address

599 NW WALKER RD
POULSBO WA
98370-8140
US

V. Phone/Fax

Practice location:
  • Phone: 360-451-9253
  • Fax:
Mailing address:
  • Phone: 360-451-9253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. RENEE MILLER
Title or Position: OWNER, CLINICIAN, PROVIDER
Credential: PSYD, LMFT
Phone: 360-451-9253