Healthcare Provider Details

I. General information

NPI: 1669830774
Provider Name (Legal Business Name): BRAIN HEALTH NORTHWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 1ST AVE S SUITE 310
SEATTLE WA
98104-2575
US

IV. Provider business mailing address

219 1ST AVE S SUITE 310
SEATTLE WA
98104-2575
US

V. Phone/Fax

Practice location:
  • Phone: 206-321-1017
  • Fax: 206-641-3246
Mailing address:
  • Phone: 206-321-1017
  • Fax: 206-641-3246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCL60528100
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1613
License Number StateWA

VIII. Authorized Official

Name: DR. RICHARD LYNN PACKARD
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 206-321-1017