Healthcare Provider Details

I. General information

NPI: 1700867132
Provider Name (Legal Business Name): RIVER VALLEY PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 OAKESDALE AVE SW STE 104
RENTON WA
98057-5226
US

IV. Provider business mailing address

600 OAKESDALE AVE SW STE 104
RENTON WA
98057-5226
US

V. Phone/Fax

Practice location:
  • Phone: 425-228-5336
  • Fax: 425-228-4540
Mailing address:
  • Phone: 425-228-5336
  • Fax: 425-228-4540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN V CONNOLLY
Title or Position: DIRECTOR
Credential: PHD
Phone: 425-228-5336