Healthcare Provider Details

I. General information

NPI: 1316037302
Provider Name (Legal Business Name): PACIFIC COUNSELING CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 03/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10049 KITSAP MALL BLVD NW STE. 203
SILVERDALE WA
98383-8903
US

IV. Provider business mailing address

10049 KITSAP MALL BLVD NW STE. 203
SILVERDALE WA
98383-8903
US

V. Phone/Fax

Practice location:
  • Phone: 360-307-8700
  • Fax: 360-692-6458
Mailing address:
  • Phone: 360-307-8700
  • Fax: 360-692-6458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00008740
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00005406
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLF00001317
License Number StateWA

VIII. Authorized Official

Name: MRS. CHRISTINA M KNUDSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 360-307-8700