Healthcare Provider Details

I. General information

NPI: 1194245308
Provider Name (Legal Business Name): AMY JO STAROSTA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 09/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-3000
  • Fax:
Mailing address:
  • Phone: 206-543-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number60773681
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: