Healthcare Provider Details

I. General information

NPI: 1295104719
Provider Name (Legal Business Name): PACIFIC NORTHWEST PSYCHOLOGY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 FREMONT AVE N SUITE 412
SEATTLE WA
98103-2709
US

IV. Provider business mailing address

17523 19TH CT NE
SHORELINE WA
98155-5262
US

V. Phone/Fax

Practice location:
  • Phone: 206-999-4587
  • Fax:
Mailing address:
  • Phone: 206-999-4587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ELIZABETH KUNCHANDY
Title or Position: PSYCHOLOGIST/OWNER
Credential: PHD
Phone: 206-999-4587