Healthcare Provider Details

I. General information

NPI: 1205174679
Provider Name (Legal Business Name): RICHARD LYNN PACKARD PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2013
Last Update Date: 01/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 1ST AVE S SUITE 333
SEATTLE WA
98104-3441
US

IV. Provider business mailing address

321 HIGH SCHOOL RD NE PMB #218
BAINBRIDGE ISLAND WA
98110-2647
US

V. Phone/Fax

Practice location:
  • Phone: 206-321-1017
  • Fax: 206-641-3246
Mailing address:
  • Phone: 206-321-1017
  • Fax: 206-641-3426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1613
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number1613
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: