Healthcare Provider Details

I. General information

NPI: 1104375443
Provider Name (Legal Business Name): ITALIA CRICHTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date: 10/14/2021
Reactivation Date: 12/14/2021

III. Provider practice location address

3438 S 148TH ST
TUKWILA WA
98168-4319
US

IV. Provider business mailing address

3438 S 148TH ST
TUKWILA WA
98168-4319
US

V. Phone/Fax

Practice location:
  • Phone: 206-832-8518
  • Fax:
Mailing address:
  • Phone: 206-832-8518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: