Healthcare Provider Details

I. General information

NPI: 1649447681
Provider Name (Legal Business Name): OLYMPIC PERSONAL GROWTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 E CEDAR ST
SEQUIM WA
98382-3403
US

IV. Provider business mailing address

PO BOX 3175
SEQUIM WA
98382-5011
US

V. Phone/Fax

Practice location:
  • Phone: 360-681-8463
  • Fax: 360-681-8465
Mailing address:
  • Phone: 360-681-8463
  • Fax: 360-681-8465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0508600
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DALE RICH
Title or Position: OWNER/ADMINISTRATOR
Credential: CDP
Phone: 360-681-8463