Healthcare Provider Details

I. General information

NPI: 1215371414
Provider Name (Legal Business Name): NW FAMILY PSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 NE 87TH AVE
VANCOUVER WA
98664-1915
US

IV. Provider business mailing address

814 NE 87TH AVE
VANCOUVER WA
98664-1915
US

V. Phone/Fax

Practice location:
  • Phone: 360-910-1522
  • Fax: 360-326-1522
Mailing address:
  • Phone: 360-910-1522
  • Fax: 360-326-1522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY60041144
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. LANDON EUGENE POPPLETON
Title or Position: DIRECTOR/OWNER
Credential: PHD, JD
Phone: 360-910-1522