Healthcare Provider Details

I. General information

NPI: 1063971703
Provider Name (Legal Business Name): SOURCE NORTHWEST INTEGRATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 E MAPLE ST STE A
ARLINGTON WA
98223-1634
US

IV. Provider business mailing address

902 E MAPLE ST STE A
ARLINGTON WA
98223-1634
US

V. Phone/Fax

Practice location:
  • Phone: 360-629-2222
  • Fax: 360-629-7074
Mailing address:
  • Phone: 360-629-2222
  • Fax: 360-629-7074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CARRIE L HARDY
Title or Position: PHYSICIAN
Credential: ND
Phone: 360-629-2222