Healthcare Provider Details

I. General information

NPI: 1063270213
Provider Name (Legal Business Name): DESTA GEBREGIORGIS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 S COLUMBIAN WAY
SEATTLE WA
98108-1532
US

IV. Provider business mailing address

1660 S COLUMBIAN WAY
SEATTLE WA
98108-1532
US

V. Phone/Fax

Practice location:
  • Phone: 206-762-1010
  • Fax:
Mailing address:
  • Phone: 206-277-5131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY.0006372
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: