Healthcare Provider Details

I. General information

NPI: 1184319782
Provider Name (Legal Business Name): PORTAGE BAY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 9TH AVE NE STE 300
SEATTLE WA
98105-4762
US

IV. Provider business mailing address

4500 9TH AVE NE STE 300
SEATTLE WA
98105-4762
US

V. Phone/Fax

Practice location:
  • Phone: 206-414-9322
  • Fax:
Mailing address:
  • Phone: 206-414-9322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY GRANT
Title or Position: OWNER/PRACTITIONER
Credential: PHD
Phone: 206-890-5040