Healthcare Provider Details

I. General information

NPI: 1053035105
Provider Name (Legal Business Name): MARISSA OHLSTROM, PSYD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4860 RAINIER AVENUE S STE C
SEATTLE WA
98118
US

IV. Provider business mailing address

3518 FREMONT AVE N # 325
SEATTLE WA
98103-8814
US

V. Phone/Fax

Practice location:
  • Phone: 206-531-4548
  • Fax:
Mailing address:
  • Phone: 206-531-4548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
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. MARISSA OHLSTROM
Title or Position: PROVIDER/SOLE OWNER
Credential: PSYD
Phone: 206-531-4548