Healthcare Provider Details

I. General information

NPI: 1275948234
Provider Name (Legal Business Name): SEAGATE PSYCHOLOGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 E MADISON ST SUITE 302
SEATTLE WA
98112-4871
US

IV. Provider business mailing address

2800 E MADISON ST SUITE 302
SEATTLE WA
98112-4871
US

V. Phone/Fax

Practice location:
  • Phone: 206-853-8257
  • Fax:
Mailing address:
  • Phone: 206-853-8257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberCP00000182
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY00002708
License Number StateWA

VIII. Authorized Official

Name: DR. DIEDRA LEE CLAY
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PSY.D.
Phone: 206-853-8257