Healthcare Provider Details

I. General information

NPI: 1922742907
Provider Name (Legal Business Name): KSENIYA SHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 E MADISON ST OFC 5
SEATTLE WA
98122-2733
US

IV. Provider business mailing address

PO BOX 51218
SEATTLE WA
98115-1218
US

V. Phone/Fax

Practice location:
  • Phone: 360-364-3613
  • Fax:
Mailing address:
  • Phone: 360-364-3613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD70030662
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: