Healthcare Provider Details

I. General information

NPI: 1629120159
Provider Name (Legal Business Name): COMMUNITY PSYCHIATRIC CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11000 LAKE CITY WAY NE SUITE 200
SEATTLE WA
98125-6748
US

IV. Provider business mailing address

11000 LAKE CITY WAY NE SUITE 200
SEATTLE WA
98125-6748
US

V. Phone/Fax

Practice location:
  • Phone: 206-461-3614
  • Fax: 206-634-0094
Mailing address:
  • Phone: 206-461-3614
  • Fax: 206-634-0094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number117700
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number035
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number17087600
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number17087500
License Number StateWA

VIII. Authorized Official

Name: MISS KELCEY SYMONS
Title or Position: ADMIN SUPERVISOR
Credential:
Phone: 206-545-2387