Healthcare Provider Details

I. General information

NPI: 1639438955
Provider Name (Legal Business Name): PREMIER THERAPEUTIC EXPERIENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 05/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8105 166TH AVE NE SUITE 202
REDMOND WA
98052-3999
US

IV. Provider business mailing address

8105 166TH AVE NE SUITE 202
REDMOND WA
98052-3999
US

V. Phone/Fax

Practice location:
  • Phone: 253-970-0779
  • Fax:
Mailing address:
  • Phone: 253-970-0779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberCO 60180142
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberLH 60270904
License Number StateWA

VIII. Authorized Official

Name: BRANDON E. STOGSDILL
Title or Position: CLINICIAN
Credential: LMHC, CDPT
Phone: 253-970-0779